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Home My WebLink AboutApplication and WCTOWN OF YARMOUTH BOARD OF HEALTH Fbe APPLICATION FOR LICENSE/PERMIT - 2016 Please complete form and attach all necessary -documents by Dece'211252016 Failure to do so will result in the returnofrour application pALTH DEPT ESTABLISHMENT NAME: 0,_,1 m e1,4 I i Sdi f(yusc- 1Ee37-ywr,44-NT TAX ID: LOCATION ADDRESS: 1341 /'c.c 0l–& Ze Of ,S, 9pnr/vlo�tq MA 0Z(AgV TEL.#: SDO 345 - Z61 Z MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: Pero L5_T12e W )"A-5 CORPORATION NAME (IF APPLICABLE): OLV.mPto 6S4 RDg5V C' ---S X /ZA/jT INC, MANAGER'S NAME: TEL.#: MAILING ADDRESS: - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1 - --= 2 Pool operators Cardiopulmon, employees belc years' records 1. 3. N� w � C , •ently certified in standard First Aid and Community I employee on premises at all times. Please list the :his form. The Health Department will not use past ain a file at your place of business. FOOD PROTE( All food service C�jWIlAxa one full-time employee who is certified as a Food Protection Maria_r Food Service Establishments, 105 CMR 590.000. Please attach cop -alth Department will not use past years' records. You must provii ,stablishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2 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. 2 HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti -choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # LODGING: PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE B&B $55 fp $80 $55 _INN LODGE $55 OFFICE USE ONLY PERMIT # LICENSE REQUIRED FEE PERMIT # _CABIN $55 _CAMP $55 TRAILER PARK $105 FOOD SERVICE: LICENSE REQUIRED FEE P RMIT # J_0-100 SEATS $125 �f6-jlD _>I00 SEATS $200 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # <50sq.ft. $50 _<25,000 sq.ft. $150 NAME CHANGE: $15 LICENSE REQUIRED FEE PERMIT # _MOTEL $110 _ SWIMMING POOL $11Oea. WHIRLPOOL $I1Oea. LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # CONTINENTAL $35 NON-PROFIT $30 J_COMMON VIC. $60 fp $80 _WHOLESALE —RESID. KITCHEN $80 LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # >25,000 sq.ft. $285 _VENDING - FOOD $25 —FROZEN DESSERT $40 TOBACCO $110 AMOUNT DUE = $ /85.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** P � SUiO/OI �na� ��'I.LI.L ?8�Y�i�'I�I.LNRid � ��2I11Z�NtJIS ��.LF�Q 'N�'Id �.LIS �If1��2I A�'L�I SNOI.I,�'AON�2I '.I.N�Y�I��N�Y�iY�iO� O.L 2IOI2Id H.L'Id�H 30 Q?I�'OS�H.L 1�g Q�A02idd�QNd OZ Q�.L2IOd�2I�g.LSf1L�i `�'�,L�`.LN�Y�idI11a� t1c1�N `rJ1�II.LI�II�'d `'a'i) 'IOOd 2I0 'I�,LOY�I `.I.N�Y�iHSI'IgF�.LS� Q003 �IN�' O.L SNOI.LF�AON� 'I'I�' 'S I OZ `S I 2I�gY�I��Q Ag �S)��3 Q�2IIf1��2i QNV �S)NOI.L��I'Idd�'"IF��1l1�1�I� Q�.L�ZdL�tO� �H.L ' N2Ifl,L�O,L A,LI'IIffiS1�IOdS�2i 2IROA SI.LI 'I£�aquza�aQ o� j ��nue f u.io.z��IT�nuu�un.i s�tuuad :��IypN , i i I •pa;iqiqo.�d s1�uauzustjq��sa a�in�as poo�ao ji��az��iq��npo�d poo��iu�3o��idstp ao`uoi��.reda�d`�uixoo�aoop�np � ��1�iI?I00�2IOOQ.Lf10 I 'u�t�aH�o p.z�og ac��uio��no.�dd�aoiad an�u�snuz`(a�tn.xas ssaa�t�nn�.za�renn u�inn�ut��as aoop}no`•a•t)sa��apis�np � . . . 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'a�i,reansui uot��suaduzo� ' s�.zax.�om�o a��gt�a� � an�u �ou saop �u�duzo� �o uos�ad ��i ssauisnq � a��aado o� �iuuad .�o asua�ij �fu��o ' j�nnauaz ao a�u�nsst piou o�paambaz nnou si u�nouza��o unnoZ au�`9 uot��asqnS `�SZ uoi��aS `ZS t �a�d�u�aapun I�iOI.L�'2I.LSI1�iI�AiQ�' 1 � i � NOTICE NOTICE � TO TO � ' EMPLOYEES EMPLOYEES , The Commonwealth of Massachusetts ' � DEPARTMENT OF INDUSTRIAL ACCIDENTS 0 � � 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 � 617-727-4900 — http://www.state.ma.us/dia � As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will � give you notice that I (we) have provided for payment to our injured employees under the � above mentioned chapter by insuring with: h H o TWIN CITY FIRE INSURANCE COMPANY o NAME OF INSURANCE COMPANY 0 o ONE PARK PLACE, 300 S. STATE ST. , 7TH FLOOR 0 � _ GYRAC'TT.GF rN 1'��n� ADDRESS OF INSURANCE COMPANY � 08 WEC TJ3961 04/19/16 _ POLICY NUMBER EFFECTIVE DATES � 301 WOODS PARK DRIVE � NUMBER ONE INSURANCE AGCY INC/PHS CLINTON NY 13323 �� _ NAME OF INSURANCE AGENT ADDRESS PHONE �� OLYMPIA FISH HOUSE RESTAURANrl', ' � 1341 MAIN ST, RTE 28 = S YARMOUTH MA 02664 � EMPLOYER ADDRESS � � � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE -- � - MEDICAL TREATMENT = The above named insurer is required in cases of personal injuries arising out of and in the course of — employment to furnish adequate 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 cost of the services '= 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 notified that - the insurer has arranged for such attention at the � � -- NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 D Printed in U.S.A.