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� TOWN OF YARMOUTH BOARD OF HEALTH ��� �,� 2014
� � APPLICATION FOR LICENSE/�� r - 1
* Please com lete form and attach all necess��i�`e `; er�ts�b �� +` m �
Failure to do so will result in the retur�of�our����c� ' . T
ESTABLISHMENT NAME: �� t o s ' �L j
LOCATION ADDRESS: � l,o� ���d D� So�� y<..».��► MA Oz t6H TEL.#: S`od Z S 8 oy 64
MAILING ADDRESS: � L,�N� �Po�...� p�{s..�a- Y��.o.��.. .�� 02 6 6�► 'ii!
E-MAIL ADDRESS: C�Gor��tv��twEt�i, Go�w►a;l. 6om '
OWNER NAME: � A. K
�
CORPORATION AME (IF APPLICABLE): Ns«.sr. �,�c_ '
MANAGER'S NAME: �51��, 1C1��,r TEL.#: S6P 28d 6$ 2 S
MAILING ADDRESS: 39 s�«�o� �. , s.� Yc��•oL�ik Mh 4z�a y ;
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 must list a minimum of two employees currently certified in basic water safety, standard First Aid and '
Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list
the employees below and attach copies of their 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• ,
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.
l. 2.
._ i'LR���T����=��:C-E: __ _ �_ _ __ _ _ _ _ _ _ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
l. 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 atta.ch 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. 2.
HEIMLICH CERTIFICATIONS:
All food service esta.blishments with 25 seats or more must have at least one em�loyee trained in the Heimlich
Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach
�
You must
rtifications to this form.
The Health De artme
nt will not use ast ears records.
copies of employee ce p P Y
provide new copies and maintain a file at your place of business.
1. 2•
3. 4•
RESTAUR.ANT SEATiNG: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $55
—INN $55 CAMP $55 SWIMMING POOL $80ea.
LODGE $55 _TRAILER PARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
>i00 SEATS $160 COMMON VIC. $60 WHOLESALE $80
— — —RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 ' >25,000 sq.ft. $225 VENDING-FOOD $25
T<25,000 sq.ft. $80 � —FROZEN DESSERT $40 �TOBACCO $95 ��=f�='�2-- -
T �
NAME CHANGE: $is AMOUNT DUE _ $ I ���~
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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� The Commonwealth of Massachusetts f
Department of Industraal Accidents ;
Office of Investigations i
� 1 Congress Street, Suite 100 �
Boston,MA 02114-2017 t
,
www.mass.gov/dia j
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name:C<,�r �oo( �►+�c►+;�r�c�
Address: �D LoNc '�u�.a �riv�c. � Sou�• �R.n�e�� ,J�'IA 02 �6� '
City/State/Zip:� y.,w��• ,M� OZ 664 Phone#: So$ -2 S � - 6'( �y '
Are you an employer? Check the appropriate boz: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. � Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Esta.blishment
2.� I am a sole proprietor or partnership and have no �, � Office andlor Sales(incl.real estate,auto,etc.) ,
employees working for me in any capacity. ,
[No workers' comp.insurance required] 8• ❑Non-profit
3.� We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing ;
no employees. [No workers' comp. insurance required]* 11.� Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other :
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is requ'ued and such an
_ _ _
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip: '
- _ _y - - _.�_ ---- ---- --
---- __ ---- -- -__
Polic #or Self-ins.Lic. # i �xp�ration�ISate: -- � �-' -
' Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpirafion date).
i Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
; fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
� of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct.
Si ature: ��%� Date: � 12 2 0l`1
Phone#• SO$ ' $0 ' 6 S L f
Official use only. Do not write in this area,to be completed by city or town officiai
City or Town: yq�Mo�Jn► Permit/License#
Issui thm�t3 ircle one):
1. rd of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
1
� Contact Person• Phone#: �g_�q€?-z23 � x �2-Yl
www.mass.gov/dia