HomeMy WebLinkAboutApplication and WC TOWNOFXARMOII7'HBO ��sr �,;; iC7���'�) �
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� APPLTCATIONFORLICENS �- 201� � ,,,, 13 2Qt2 �
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•Pleaee complets form and attach all n�es�y dou�m 012-
Feilure to do so will result itt the rotu�+df'yodr appli on pac et, �,, -,, n�07,
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NAME OF BSTAHLI$HMENT: DUOkIn' DonUtS TfiL.#
IACATIONADD[LESS: 16 E. Main Street
MAILINGADDR£SS: '164 Main Strn � to gham MA(J�$0
OWNERNAM$;. Salvi Cnuto TpXID(F INorSSNI� ne_n�cp�da
CORPORATION NAME(IF APPLICAHLE):�aDe,M��gp,tqent Team. 4LG.
, MANAGER'S NAME;_ Don Mar�enald TEL. IE,j$1_ 79�0�
MAILINGAADRESS:._ iaoiu��nc*�ee c►„�etiam nnnos�sa
POOL CERTIIrICATIONS:
The pool aupervieor muet be certifled aa a Pool Operator,ea required by State law, Pleasa liat t6e designatcd
Pool Operator(s)aad attach a copy of We certificallon to this form.
1. Z,
Pool operators must Ust a minimum oftwo empbye�es c�irrently certified in basic water sefety,standard First Aid md
Community Cardi��u�onary Resuacitadon(CPR,l3leass list these employees bclow end ettech copies ofemployee
certiftcadons to thfe form.The Health Department wiU not ase past years'recorda. You must provide new
copies and maintein p file at your place of bastnese.
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1. 2.
3. _4.
FOOD PROTECTION MANAG&RS=CERTIFICAT'IONS:
All food service eatablisfimants ere required to have st leesrone full-time employee who is cercfficd as a Food
Protectiott Manager,as dofined in tho State Sauitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach coples of cerdfication tp this application. The Heak6 Depertment wtll not use pest years'eecords.
You maat provide new copies and maintain a tile at yoar eatablishment.
1, Deborah Flemin9 z, i
PERSON IN CHARGE:
Each faod establishment must have at leert one Person in Cherge(PIC)on site dwing hours o£operedon.
� Deborah Fleming 2 .
HEIMLICH CHRTIFICATTONS:
All food service establisluneuta with 25 seats or more raust have at t�ast one emplo ce trained in the Fleimlic6
Maneuver on the premisea at all timea. Please list your anptoyeea trained iu anti-choyking procedures below and
attach copies of employee certiScatiopa to this form, The$ealt8 Department wfll not use past yesrs'records,
You muat provide aew copies and maintaln a tile at your place of bualnesa.
1, ' 2,
3. 4.
RESTAURANt S$e4TING: TOTAL# 0
i.oaaING: OFFICE U$E ONLY
- LIC8NS8REQUIREU F66 pHRM77'# LICENSEREQUIItED FG6 PfiRt.flT# LICENSENEQUIRRD FEE PERMITe
_B&H 345 _CAB1N S55 - _MOtII. - 555 �
. 1NN, S55 _CAMP S55 , _SWIMA9NOPOOL S80ee.
_LODOH S55 _YRAll,ERppRK SIpS _WHIRLPOOL S80.x.
� FOOD$SAVICSi . ,
� L1C�13EREQI1RtGD FCE PE[tM[f# �LIC6NSEREQUQtED ff,G P&RMITA LICL•NSEREQUIRBU FEE'�PERAfffl7 � .
. .La10038A1'8 S69 �/3�/� —CANTWENI'AL S35 NON•PROFiT S30 .
� ,�>I009EATS f160 �COMMONVIC. SGO -_WHOLESALE E80 . . . . �
� �- RETAIL BERVIC&: � �RESID.KITCFII;N S80 .
. . � I.ICfiNSBREQUIRED F6E P6RMITN LICBNSEREQULL2ED FEE PkRMI'I'S LICENSEREQURtED FEE .PERMI7'iF �
. . � . �„cSOp.R. S50 _>25.00Oaq.G, 5225 _VENDINO•FOOD f23 �� - . .
. _QS,OOOaq.R. S60 _FA02END6SSfiRT 8�0 �,_I'ODACCO 554 . �
Nnhm,c�uivoe: s�s AMOUNT DUL � S .SF+ 0�
� . . •••••PL6AS&TUAN OV6R AND COMPL&TB OTAER�E OF FORM••••• . . . .
x ADMINI3T12ATI01�T . ¢.�-J'
YJnder Chapter 152,Section 25C,Subaection 6,tUe Town ofYarmouth is now roquired to hold Ia9uance or reaewal
of aay license or parmit to operate a businass if s poraon or company daes not have a CastiBcata of Worka's
Compenestlon Insurance. 1'HE ATTACHED STATE �'ORKER'S COMPEN3AITON IN$URANCE ,
AFFIDAViT MUST BE COMPLETED AND BIGNED,OR
CBRT.OF TNSLIRANCS ATTACkIl�D_____. . . . _
OR
WORKSR'S COMP.AFFIDAVtT 5IGNBD AND ATTACHED X
Town of Yatmouth taxes and fians muet be p�d prior to ranewal or iaeuance of your parmite. PLBASS CFTBCK
APPROPRIATELY IF PAID:
XE3 X NO
M01�I..9 AND OTHER LODGING FSTABLI3H➢�NT3
TRA.NSIEN'I'OCCUPANG`Y: ForpurposeaofthaUmitationsofMotelorHotelusqTiansientoccupancysk�allbe
limited to the temporary and s6ort tarm occupancy,ordinarlly and caiatomarlly associated with motal and hotel uee.
Transient occupe�rta must have and be able to demonstiato that t6ey maimain a ptindpel place ofrasWence elsewhera.
Tranaiant occupancy al�all genarally refer to conGmxoua occupancy of not mora than thirry (30) days, and an
aggregata of not more than ninety(90)days withip any six(6)month period. Use of a guast unit as a rosidawa or
dwelling unit shsll not bo considered usnsiant. Occupancy that is aubjed to the colleotlon of Room Occupancy
Excise,as de8uefl in M,G.L.a 64G or S30 CMR 64G,as amandcd,shall genarally ba conaidarad Trenaim�t.
P007hS
POOL OPENING:All swimming,wading aod w��ols wltich hava beon cloged fottha eeason muet bo�uep ected
by the Heatth DapartmeM prior toopening. Contact tha Health Departmeat w ac6edule tha{nspecUontlu�ts.)days
pnot to opening.PLSASE NQ'fH:People aze NOT allowed to sit m the pool area ura�tha pool hae bea�t lnspected
and opened.
POOL WATER TES'fIlHG: Tha walar muat ba tested for paoudomonas total wliform and atandard plata count
by a State certiSed lab; snd submitted to the Aeakii paparhnant tfvce(�S)days prior to opaning, and quartarly
thareattor.
POOL CLOSING:Svery outdoor in ground awimmiag pool must be drained or covared within eevea('n days of
cloeing.
FOOD SERVICE
CATERING PQLICY�
AnyonewhocatarswithintheTownofYnrmouthmuataotifythaYamwuthHenithD�tby tharsqu�red
Tem}orary Food Servica Application form 72 hours prior to the cntered evemt. Thesa Ponne csn be o ' ed at the
xeatth nepecm,ent, ,
FROZRN AES3ERTS:
Frozon dasserts muat ba tested on a monthly besEs by a Stau cortiflad lab. Tast rasults must ba senito the Hoa@h
Departmeut. Feilure to do w will resuk ia tha eusponeion or rovooation of your Frozan Daesmt Permit until tlia
above tarme hava beqn m�.
OUTSIDE CAF�S:
Outsida cefes(i.e.,outdoor eosting with waiter/waiq�ess servlce),muet hsve prior approvel SnmthaBoard ofHealth.
OUTDOOR COOKIIVG: •
Outdoor 000king,proparatioq or display ofany food produd by a rofail or food eervice astabHshmont ie protiibihd.
NOTICE:Pannits mn anm�ally from January 1 to December 31. Tl'LS YOUR ItEBPONSIB111'1'Y TORETURN
TI�COMPLETED RENEWAL APPLICATION(3)AND RSQUIRED FEH(S)BY DECBMBER I5,�Ol 1 '
ALL RSNOVATIONS TO ANY FOOD &STABLISI�ffiNT, MOTEL OR POOL (i.a, PAIIdTWG, NBW
EQUIPMSNT,STC.),MUST BE REPORTED TO ANA APPROVHD BY 1HS BOARD OP HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY 1 QUIRE STTE PLAN.
DATE: I d'I( ' I� SI6NA �. �
PRINTNAME&TITLE: SelVi COUtO
osnsro9
� � The Cornmonwea/th ofMassachuselts
Departn►est of IndastrialAccidents
INfaN�
600 WasAingtoa Street, 7"�Pfow
Baston,Maas, 02111
Wohers'CoupeesaHe�Imvasoe Aftldark:
Mease PRi�1rP• ••-
oame: n��nkin Donutc
a2�s: 16 E Main Street
ci wpef Varmrnrth amte• ^Ap "n (17R7� � # 5O$ 8B9 (119d
work site locetion(fvtl a�Lhcvsl• .
❑ I am a homeowner performiog all wock myeolf.
❑ I em a sok propriGor and Bave no one wo�lCieg in my capacity.
� I am an empbY�P�'�din8 wotkeas�compensation far mY�PbY�wo��Ciog�thia job.
��.�: (=aoeManaaementTeam LLC
a9�.- 169 Main Street
de.: Stoneham. MA02180 ��. 781 279-0290
1�red AmTn�et Financial Seroices In �R^ TVyC 3314456
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[am a sole DroP��,�al eo�tract�r,or iwsnw�er(curle nws)and have hired Wo cootracWis listed bdow who have
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