HomeMy WebLinkAboutApplication and WCI �I�V�IJ V Lw L
a � , TOWN OF YATdMOI7TH BOARD OF HEALTH
ATPLTCATIONFOItLICE1V3E/PERMl1' 20�; � ; DEC 1 � �`C'�9
*Please complete form and attach all necessary doawnanu �' `
�
Feilure to do so wlll mault in the reharn of your apphcatton pac , 1L. HEaALTH DEPT.
; NAME OF ESTAHLI$ NT: Dunkin' Donuts TEL,#
, LOCATIONAADRESS•H�. Main Street
MAILINGADDRESSc' 1fi9 Main Strnet tonphap7, MA 027$p,
OWNERNAMfi:�alviCc���tn TA LD(FEINoryS$L41;.,f�Q7Ro�da
i CORPORATION NAME(IF APPLICABLE):�aoe Managpment Team. GLG
. , MANAGER'S NAME; Fddiw Correia TEL.# 781_979_0990
MAILINGADDRESS: �aq �n ' Ctroet StnREh87Jt AAA.I12780
POOL CER'CIFICA7'IONS:
� The pool eupervlsor m��st be certified aa a Poal Operator,es required by State law. Please list t6e designated
� Pool Operator(s)and attach a copy of the certificarion to tLis form.
1. Z.
Pool operators muat list a minimum oPtwoemployees cmreatly certified in basic water safety,standard Firat Aid and
Commwiity Cardiopulmonery Resuscitadon(CPR,1.1'lease list these employees below and attach copies ofempioyee
cert3ftcarions to this fotm.Thc Health Depertment will uot ase past yeArs'records. You muat provide new
copies and m»Intefn p flle at your plqce of buainess.
�
� 1. 2,
3. _4.
FOOD PROTBCTION MANAGERS=CERTIPICATIONS:
All food service establisLments are required to have at leesrone full-tune eroployee who is cenified as a Food
Protecdon Manager,ae defined iu the Stau Sanitary Code for Food Service Establishments, ]OS CMR 590,000.
Pleese attac6 copies of cenification to this application. The Heaith Departmeot will not use past years'cecords,
You muat provide new copies aod maintnin e file at yoar establiahmeut.
1, Denise Cook Z �
PERSON IN CHARGE:
Each food esteblishment must have at leest one Person In Charge(PIC)on site dwing hours of operauon.
1 Denise Cook
2.
HEIMLICH CERTIFICATIONS:
All food service establisivneuta with 25 aeats or more must have at (east one employce� trained in We Heimlich
Maneuver on the premises at ell times. Please list youremp loyees trained in anti-choking procedurea below and
attach copies of employee certiScedons to this form. The Health Department will not use past years'records.
You must provide new copfes and maintein a Hle nt your pisce of bualaess.
I. " 2.
3• 4.
RESTAURANf SEe4TING: TOTAL#�_Q____
i.onaINc: OFFICE USE ONLY -'
- LICENSEREQUIRED F56 PERMITN LICENSEREQUIRED FC6 PERt.97'# UCFNSGAEQUIRBD FEE PERMITM
--BhB S55 _CAB1N S55 - _MOTA, � S35 �
. . _�NN. SSS _CAMP 555 . _SWIMA9NOPOOL SBOee. - .
��LODOB S53 _'fRpll,gRPARK S105 _WEi)py1+(�pL SBOea.�,_
� T+OOD SSRNCE: . ,
� 1dCBNS$i�EQUdt66v FGE PF[tMlT# /r�] -�LICfiNSEREQU11tEp �FFL PbRMITk UCGNSEREQULLtBD €EE ,PERMITN �
L0.100 S&1T3 t85 Z�F F v—CONf WENl'AL S35 �NON•PROF7T S30 . .
. ,;_>l009EATS 5160 �COMMONYIC. SGO � WHOLESALE 880 � �
,� HETALI,BERVICE: —RESlD.KITCHEN 380 .
WcaxsBrtFRulxm r�e r�at�fira L�ceruet�Qvuten � ek:reMrrs LICENSEREQlliRED FEE PERMITq
. . - . �<30 nqA SSO _>2$.000'q.& 5433 _VENDINO�FOOD S25 .. � . . . ���'.
- _a5,00D.aq,R. S80 _FROZFNDL+SSER7 S40 ,_TOIIACCO S55 . � � �
. � NAMECIrAN6E: . .Sli . .. . - . - � . . � � AMOUNTDU�' _ � B�'i_ (�(� ��T_ . .
. . •''w••PLB,A3ETURNOV6RANDCOMPLET66T1iCR9IDEOBFORM"••'« �� ....�� ..,.. ."•*'��. . I
�u.,�S' '
� ADI�IINIST1tATION ' ¢""�
Under Chapter 152,Section 25C,Subsection 6,tha Town of Xarmouth is now required to hold iasuance or reaewal
of eny license or pennit to operate a busineas if a persou or company doee not have a CarliScata of Workar's
Compmeatlon Insurance. THE AITACH$D STATE WORICL�R'S COMPEN3ATfON 1NBURANCE
AP'FIDAVIT MUST BE COMPL�1'ED AND SIGNED,OR
CERT. OF INSURANCE ATTACI�D_,_,_ �
OR
WORKER'S COMP. APFIDAViT 5ICrN�AND ATTACkIED_�
Town of Yarmouth taxea and liane muet ba paid prior W raneaal or iaeuance of your parmita. PLSAS&CHHCK
APPROPRIATELY IF PAID;
XE3 X NO
MOTE[S AND OTHER LODGING E9TABLL4HMENTS
TRANSIENTOCCYTPANCY: ForpurposesofthalimitationsofMotelorHoteluae,Translerttocxupancyshallbe
Gmited to the tempora�y and short term occ�psncy,ordinarlly aad wstomazlly assoolated with motel and hotel uea.
Transient occupants must have and be abla to demonstiata thst they maintain a prindpal place ofieaidence elsawhara.
Transient occupancy al�all generally refar to co�ous occupancy of not mora than thitty (30) days, and an
aggragate of not more than ninety(90)daya within any six(6)month period. Uae oFa guest unit as a rasidence or
dwelling umt ahal(not be considerod hansiant. Occupsncy that is eubjed to the oolleoHon of Room Occupmcy
Sxcise,as de8qad in M.G.L.c,64G`or 830 CMR 64G,as emended,ehall genara�ly ba coneldarad Transient.
POOLS
POOL OPENING:All awimming,wading and wLirlpools wBich have bean cloged fortha eea.4on muet be eaed
by,theHealthDepertmen_tpri�o��r_t_o�openiag. ContacttheHealthDepartmenttoachedulatheinspectiontLra��( )days
pnor to open'u�g.p,S�!tiB NUl'ri:peoPle are hIOT allowed to sit m the pool aren uat7 the pool has bcen laspacted
and opened.
POOL WATER'1'E8'CII�iG: 1'he water muet bo taetad for paeudomonas total wliform md atandard plste count
by are�� cardEed lab; sad submitted to the Heekii Aapartma�three(�)deys prior to opening, and qua:torly
the
POOL CI.03ING:Every outdoor in ground swlmming pool must ba drained or covered v✓ithin eevea('�days of
closing.
FOOD SERVICE
CATERING POLICY:
AnyonewhocaterswfthinthaTownofYarmouthmuetnotifytheYarmouthliealthD�rtby�tl��equ6'ed
Temp orary Food Servica Application forn�72 hours prior to the cetered aveM. Thesa forros can ba obtained at the
Iiealth Daperunent. ,
FROZEN AESSERT3:
Fmzen desserta must be tosted on a monthly basts by s State c�dflaei lab. Tast rasulta must ba�to the Health
Departmeeott. Feilura to do w will resuh ia the s�ispension or revocarion of your Frozon Dacsert Paruit until tUa
above terms have been mat.
OUTSIDE CAF�S:
Outeide cafba(i.e.,ouWoor aeating wlth waiter/waltresa sarvice),must hsva prlor approval fromthaBoud oPT3enhL.
OUTDOOR COOKING: ,
Outdoor cooking,prapara6oq or display ofany food product by s refail or food aervice eatablisbmart is protiibihd.
N07TCE:Permits mn anm�ally from Jenuary 1 to December 31. 1T L4 YOUR KE3PONSIBII.I'1'Y TORBTURN
TT�COMPLETED RfiNBWAL APYLICATION(3)AND RSQUIItED FE6(S)BY DSCBMBBR 15, "ZQj� •
ALL REIQOVATIONS TO ANY FOOD &STA$LISI�lvffiNT, MOTEL OR POOL (i.e., PAtNTING, NEW
BQ[JII�MENT,STC J,MU5T BB REPORTED TO AND APPROVBD BY THS BOARD OP flEALTH PRIOR
TO COMMENCEMENT. RENOVA'[ZONS MAY REQUIRE A.SITE PLAN.
DATE: �I�O '�I SICiNATURE` ,
PRINTNkME&TITLE: S31V1 CoUtO
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� The Co�nmonwealth ofMassachusetts
Departe�ent of Irtdastria!Acciden[r
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60B Wwshingtoa Streey 7tb Ffaw
Boslan,Masr. 02111
Wohers'Coupeesatis�Imvasee Aftidavk:�
�a11t i1�Uu: fiease PRllV'f leelbh
name: Ilunkin Don �tc .
�s: 16 E Main Street
eiN 1Nacf Varmn�ifh amte• ��A zin• 0 67� a�e# 50$ 869 �'12d
woslc eite 1«ation(foll add�essl: .
Q [�a homeowna perfmmtog au wrotic myaolf.
❑ I am a sok propaietor and 6eve no a�e wodciog in any capacity.
� I am an empbyer�aoviding wocke�s'compensatim far my employees working�this job.�
���,rrm�: Caoe Manaqement Team. LLC
a��,: 169 Main Street
eh,: Stoneham, MA02180 ��. 781-279-0290
I�ca AmTr�ct Financial Serviceq, Inc. py�� TW�3�8Q��
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❑ I am a sole praprietoy�eral ewtraetsr,or Yoseew�er(corle nue)end have 6ired tl�e cootrectas listed bdow wlw heve
tLe folbwiog worke�s'�tion polices:
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