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� � ► TOWN OF YARMOUTH BOARD OF HEALTH �� °
� � APPLICATION FOR LICENSE/P��I�"`I' -� 1��� j ( � `, ��� �; 7 2��5
`'� * Please com lete form and attach all necess ,dQc , �� . e er 15 2015.
' p � ' ��" ��¢_i n ac et. HEALTH DEP
Failure to do so will result m the return o��our appYicat o p T.
ESTABLISHMENT NAME: �N N � T CA ��. Co D TAX ID:
LOCATION ADDRESS: 4 Su rn M ��R ST� YR RMo uTH Pa RT TEL.#:5 08 3 75 05 9 0
MAILING ADDRESS: P o �o� 3 7 / '' �
E-MAIL ADDRESS: S�Ay�„�na��aD2coc� -�M
OWNER NAME: M 1 CN A E t- -t H �1-E� CA 5 5�c LS '
CORPORATION NAME (IF APPLICABLE): "'i'}�E �N c�1 Pt�T C.�!PE Ct�t�, �-L C
MANAGER'S NAME: A S c�b o 1 e TEL.#: c, S a.b„.1 e '
1VIAILING ADDRESS: ' � "'
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law ase list the designated
Pool Operator(s) and attach a copy of the certification to this form.
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Pool operators must list a minimum of two empl s currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), hav' one certified employee on premises at all times. Please list the
employees below and attach copies of ' certifications to this form. The Health Department will not use past
years' records. You must prov' new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food '
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. 1'I �LE� �� SSELS 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1 �E�..�iv��"�'�SS�L-� 2 "
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ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach ;
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment. ;
1. ��LC-�l � S S E L..S' 2.
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HEIMLICH CERTIFICATIONS: i
All food service establishments with 25 seats or mor have at least one employee trained in the"Heimlich
Maneuver on the premises at all times. Please ' our employees trained in anti-choking procedures below and
attach copies of employee certifications is form. The Health Department will not use past years' records.
You must provide new copies a aintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL# '
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LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
�INN $55 � CAMP $55 _SWIMMING POOL$110ea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE: '
LICENSE REQUIRED FEE PERM�T# LICENSE REQUIRED:FEE PE�MIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 fo� �b' _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 �COMMON VIC,, $60 �3 _WHOLESALE $80
.�;;' •°- � :F � '�� �RESID,.KITCHEN-$80-_ �
RETAYL SERVICE: - � ,. . _ . ._ _ _: . _. :. _
_ .
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 '
NAME CHANGE: , $15 . , AMOUNT DUE'- $ �.�}O •O O ''
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{ � NOTICE NOTIGE
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EMPLOYEES _ .: � � E1�PLQYEES
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The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
' 600 Washington Street, Boston, Massachusetts 02111
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As required by Massa.chusetts General Law,Chapter 152, Sections 21,22&30,this will give you norice
that I(we}have provided for payment to our injured employees under the above-mentioned cha.pter by
insuring with:
N�RFOLR & DSDHAM MUTUAL FIR}3 INSURANCS COMPANY
NAME F E MP
222 �MFS STRFs13T DSDHA��, MA 02026
WEO£i4424A 12101f2015_ '
�'OL� Y ER EFFECTIVE DATES
434 ROUTB 134 SOUTH
ROGI3RS & GRAY INS. AGBNCY, INC DSNNIS, MA 02660
SOOTH DF1�II�iIS OFFICB
F ADDRESS PH NE#
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T�FS`INN AT CAPE COD LLC YARM�HPORT MA 02675 5U8-790-0590
EMPL YER ADDRES
10/23J20Z5
EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF AN� ��i'�E
,, : : ,
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequaxe and reasonable hospital and medical services in accordance with the
provisions of the Workers'Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cast of the ser-
vices provided by the treating physician will be paid by the insurer,if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby norified that the insu.rer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Form WC 88 20 01 C Printed in U.S.A
INSURED COPY
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