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HomeMy WebLinkAboutApplication and WC�� r 11/26J2�12 60:4E 61�3�23150 STAPLE5123 v'�i FAGE 01iE4 r�ii._ �J'uw�. � �v��..,�ti � � �� ������ �� ; . �°� '�owav oF Y����ou�Fi iao ,_ .. T� , �:� ��` �uG�l��^. APP�ICATT,ON t��oa�U�►cENs `�`� r �� r , ,.��a9 � (!'� 17_ � �Plca�e com.pl,ete form,and a,itac.h:A1 necess docainencs by.Decen:ber,i5.2011. ! ra���zo ao 5o W�i r��sult i:i d�e return of,your application pac et. � I �5TAJ3LISHNf�NT NAIvIE: -Cn✓� U.�- �C: Iw 1�•. �,A t TAX�3• .�� � ` LOCATION AT)DRESS: �7 A n!" "b;�l_Ut. �f UvvYl J l� TEL.#: " i$ -�1 I- 3U�� � MAILING ADDRFSS: '� ' �E.Ir.1�,Lt�.! '�` ✓ ' �-<l3 OWNER NAME: rTcTL�S& �-T�C'� ,?�. - •: _ ; CO]tPORATION NANIB(IF AP�LICABI.�):_„_=nr�caa-- ��.v.1�i,5 Ir�y ' MANAGF.R'SNAME: " l _:1G�. TEL.#: �.I-�0�� ..?�4ZC.1-�] � n4AIL�NGADD]7ESS: 'i c: Lvc. ��.,✓Mn� ���V1�7u�b��_ ��, PdOL CE�ZTIFiCATIONS: The pool su�ervisor�ust be certitied as a Poo1 Operai;or,as required by State law. Please Iivt thc desiguated �'ool Operator(s)aixd atiacl�a copy of the certif"ic:.�t;ion to this£onn. i. iJ/'�+- 2. Pool operators must list a minimuin of[wo eznplpyeey cu�x _ce�Ei€�e�in�asic wace�safety,scandard First Aid a�ad Comraunity Cardiopulmon,ary Resuscitatioa7.r'a;:P'�7" lease list these employees below Latiacli ca�pies of :mpioyee cen�fications to th,is forn�. ealtla De�a.rt�ent wi1.1 �ot use past �ecnrds. Xou nau.st provide new copie9 and main ' ile at your�ulace r:J'busi�►ess. I. I� � _. 2. /� 3. � 4. F�OD PROTECTI�N R�I�1N�1G�R5-CERTTFIC::'�TIOt1S: All food service establishmei�ts are required to h�'�re ac I:ast one full-citne euiployee who is certifzed as a�oal Procection Manager,as de�ned in Uie State Sanit�u�y Cvd e for Food 5ervice�stablishments, 105 CMR 590.000. Please aCtach copies of certif ca[ion io this applicar,.c,n. Th�e Healtlt Aepartruent will not use pas t.yexrs'records. Xou must�rc►v�de new copies and maintain a f11�,:at ya�ur establishment. l. T2f�'Sc.• �-• 1�,c�vlC. .., 2• P�RSON W CHARG�: Gach fooci establi5h,.ne��t must have at least onc Pe:rson Ira Charge(PIC)on sitc durit�hours of crperation. ].. e��S G � L � ��`��v/`c� _ 2. HEIMLiCI-i CER'TIFiCr1TIONS: .n71 fi�ed�s+�N�b}is�a3en�r+�it�t-?��se�fs�r-rnat�c--rrz-i ;n-the Heirzuic.�— Maneuver ou�the pxemise,s at all times. Plcase lis�yrour e�n loyces trained in at�ci-choking procedures below and a�tacl�copies of employec cerlif cations to this forzn.. '['he�eaitta Departu�ent will not ase Qas6 years'reco�ds. Xou must Qrovide new copies and ma��tain a�nlc at yr�ur place of busiuess. 1. J�� �' � � 2. 3. , _ � P.ESTAURANT SEATZIVG: TOTAL# ._, ,� _�r....�. OFI+I:t:E U��ON�.Y LODGWG: 1..ICENSE REQUtStL-A F73F PERMIT a �,ICBNSE RE(2'IiIREb FET PrRM1T# LICE,�IS�REQUI�LEO nEE PLR�iIT� �I3&�3 y:55 ,..�CA.B[N 355 _MOTEi. $55 INv $55 �CAMP S55 _SWIM.�IiNG PO01. $ROea �L011(3E $55 _,TI2A1,t,LR P,4RK 5105 _WHIRLPOOL S80e� FOOU S�RVICE: LiCENSE REQUIRED FEE PERti11T# LICENSP R�.�)lJLRED FEE 1'ERi�irT i1 L.ICENSE REQUIRED FEE pBttM�T�t 1_a�oo senrs $85 _COv7't�f�;v'I'A[, S35 _NO�-PROF[T S3D >100SEAT5 �160 �COMti(U�'��iC. SGO _wHOLESALE �80 . RrTA�,SER�ICE: —RFSID.KITCHEN 5Ap '� LI(_"L�Sr Tt�QU1RED CL-F PFR,ti1IT S LICENSE RFI.)1.JIRF_p FEE PE1tMlT�! LxCENSE REQIi[RED f•EE PERMIT# �<50 aq.ft. $50 _>25,000 sq.fl• 52�5 _�ENDING-FOOC �25 _/�5,000 sq.fl. SiRO _FROZE\."�I;:SST:RT �40 _TOBACCO 59S 1 .�'A.LIE CHAYG�i: $15 A.MOUNT DUE = ���� '�+�"pLEA5E TCIL'V O�R A�'ll�CnMP:ETE OTHEA 5IDF O�'EORht'•'""' ( 11/26/2012 00:4B 6103723150 STAPLES123 PAGE 02/04 � The Cv,n,na�.�zwea,l'th �f 1Nassach�+setts i Departme�aot of,[rrdwstriat Accidentc � I�IY�1�P 1� � 600 Wd���O�i,��toa�►Street, 7��Ftoor � ��►�taa,A��`a�a 0,2�1,C y Wwrkc*s�C4nlpl��tRaA�Ik�AR'�1NC�,Af[id�1N'�t: � —UI�I�.�����....�� ! n���- �t2E �.E.��T�{, S\�Cq.h�,�., ��._v.� Gw,'1�c�,5 ����;.(� . l 2 � _ --�.�� . -7 �`_l �f� ��I��N u�� � add�ress_--�..1._.._._...__�'.�.,........__._..........._._...___-----_.d.._.__.----...---- -- �_�_...,._.._._.r_ - -- �� ���� ���M 0 v�� 9�c��..C�--I �;. �;o• ���"I�,n�n ��U--`�C7 -- �(. , �.r��;r•location(fvll addreeal� �._. ❑ �snn a bnmoowner perf"arming s►l1 work myse�f. -.�,-..-;-� �I ecn a 5ale ptoprtictor and t�ave no one wp;king ir��pm�cap�+city, ❑ i aun ae cmP�oY�Providing worke�'compensati�r�kbr my c��ployecs working an this.job. 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Da� �1��V=��1��c'� e7� ,_' f� !l -{_� P[uN hat�c � G��'� ����l��.f-! �'(e`��";� TI Phvne tl 4��-���,`�.�`.?�._. . � �AR��M�IARN411�� offlchl e�e enly dn n�t�rlte M thlr arr�1�be complcled qT�I'�ry'��Is�ivN ellklr�l ciEt nr tmm• �,i._� xTmkJfloCef�t�1 ❑8aW1nR Depirrlwieet ❑�Jcew�Rea►[�I (]chedc Iffm�wedl�k;rtfpnnle(n�[�Vd� �9eleahwcs�"s C1A�ct �I#erltM Dq►+rtr.tat cnnt�et ptnM�q: p1M�ee M;� �Q � ' (eeK�Qq+.1tM71 � 'NAIi�fI�00R11 � i � t 11126/�012 00:48 6103723150 STAPLES123 PAGE 04/04 . * �opy�printcenter � Complimentary ��Ifi-�:►erve Fax Cover She�t ; From: ��� '�rC�_ i Ta��� v J � .�, .,._._ �� � Fax#: ���..��" 34'��: Phone #: L.�-�l ..��..� `�.�.�,�.— Date: ._ _ a� _�.r..� ��Ply Fax #�-- - -_. � � Number of Pages (In over): Urgent �Confidenti�l [] Conf�rm Receipt [] � G� _� `��[i���1��� �k�nl:� .�tJ r. J i �-�1�,+��.'..�-� ���'I. � I INe'11 do it right ����e fii��st time — guaranteed. 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