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Home My WebLink AboutApplication and WC �" �� Jf��' � �'I � TOWN OF YARMOUTH BOARD OF HEALTH ; � � RECEIVED �APPLICATION FOR LICENSE/��I �2� �: : Ec �O ZO 1L . � �;�:� ��r f � OCT 2 5 201�lease complete form and attach a11 necessa�y�;doc��rits`by '.i�ce ber pT. Failure to do so will result in the returri of your application p � ESTABLISHMENT NAME: � S m��- � ID: :� �� LOCATION ADDRESS: �. � �.c; � ��-I'h TEL.#: � �' ��/ MAILING ADDRESS: S 2, M �1c�-'�S '� � OWNER NAME: armacy, t1C. CORPORATION NAME (IF APPLICABL ): MANAGER'S NAME: � '-CY� C C 0�.. TEL.#: `t'� ` MAILING ADDRESS: �) �, a� � U �T ��' S 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). Please list these employees 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. _ -��C�D-�P.Q2'E�T'�Cl`d�bi�`�PrAf'r�R�- �:EgT�F�£�,�3�TS: _- _ _ __ _ _ --_ . 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. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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# 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 PERNII7'# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 �<25,000 sq.ft. $80 ��j_.(��K —FROZEN DESSERT $40 �TOBACCO $95 (3'�3�J NAME CHANGE: $15 AMOUNT DUE _ $ I 7S .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � • � � �'he Cammanweulth of'll�dassac�iaasetts .��purrtm�nt of 1��dustriar114cci�ir�ts �ffiee ofY�av�stigatio�as 60�I �ashirzgtnn�S`treet �ostvn,��9 42III www.mcass.gov/dia� ''�"V��ke�s� Gat�tgens�tia�n I�asiaran�e�d�vi�; �n�ar�l.Busia�ess�s A�licant��afo�-�at�on �'lease�a�in��.e�ib1� I3usiness/Organizatian Name:_. CVS/Pharmacy # /�� l � Address: �2�O�fl'�-�,J-e. �-�' �(�ll�,�i.i ��U�w�j�,., CitylState/Zip: �A �°��-'�`� P'hone#: �J��"�'�'�'��Cj Are you an employer?�h�ek t�e app�o�Oriate bva: Busiaeess T�fre�e�ired): I.� I am a emgloyer with e�ployees(f�lt and/ 5. �Retail ar part-[ime).* 6. ❑Resta�zranit'Bar/Eating Establishment 2.❑ �am�sole�ropriefior or partnership and have no ?. ❑Office and/or Saies{incl.re�al estate,auto,etc.) emp�oyees working for me in anY capacity. � [No workers'camp.insurance requiredj �. ❑Nar�-pr�f�t 3,� '�Ve are a r.orporation and its oflicers have exercised 9. ❑Entertainment their right of exexnption per c. 152,§l(4),and we have l U.Q Maraufaciu�ing no emplayees.[No workers'camp.insurance required�* 4.❑ We are a non-profit organizarion,staffed by volnnteers, �I.Q Health Care with ao erngloyees.[No wrnkers'cornp.insura.nce req.) ' 12.�]tlther *��Y�PPlic�nt that checks box#t�n�ast atso fiIl aut the section below showing their work�rs'cmmpensation policy information. *:if thc corporate offioers have ezempt�sl themselves,but:the car{wration has oiher employees,a tvorkers'campensation}wlicy is toquired mui such an org�ixeeion shoula check tnox#1. l am an emplt�yer that is provading workers'ct�mpetrsation�nsumnce for my emptayees. 8elow is the pulecy information. A _� Insursnce Company Name: New Hamshire Insurance Company Insurer's Address: I�5 Wa t er S tree t New York, NY 30038 City/�tate/Zi�s: Policy#ar Self-ins.Lic.# 43 0 9 74 09 ��: OI/O1/2 013 �tfach a copy of the workers*eomxpensation palicy rleciaratios�p��e(showii�ng the galicy nuffiber�nd e�par�teon date). �`ailure to seccire cowerage as r uired under Section 25A of MGI,c l. �1 . 52 can lead to t�te�znpositian afcrirninal penalties of a fine up to�I,500.0�and/ar ane-year imgrisanznent,as well as civi�penalties in the forrn ofa STOP WORK ORDER and a fine of ap tv$250.00 a day agaittst the violator. Be advised that a copy of ihis statement m�y bc forw�arded tfl tha Office Qf Investigatians of the DIA for insurance caverage verification. 1 do herehy ce ,u�der tke par and p naltres o.fPerJury tltat the artfarmalivra prm�ided abnve is true uredrorrect Si tttre: _ -..\ Dafe: �� ` �� , Phane#: 4 01-77 0- 72 Offuial use only. Do not write in this areary,tttss Be co�pdeterl hy cily ur town a�ciuL �aty or Town: xl�r�.�.lo�}�Cl� Permifil�,icense# c4rcie an�): i.B ard!of Heatth .Bullding�egar[men# 3.�'ityi'Y'own�ierk 4.Licensintg�fosrd 5.�Selectmen's Uffiee �oatact Perso�a: P'h�a�e#: 5�R-39�3-�a-�/ ) 1�� www.m,aass.gov/dia , I i i . i ' ; C4MMONWEALTH OF MASSACHUSETTS , DEPARTMENT OF INDUSTRIAL ACCIDENTS OFFICE OF INSURANCE Setf Insurer CVS/Caremark Cornaration and its subsidiaries Reinsurer National Union Fire�nsarance Camnanv of Pittsbur�h,PA Contract Period from O1/01120�2 to 41/01/2013 Contract is a � Catastrophe Policy XX Policy No XWC 119-24-74 Aggregate Excess Self Insurer's Retention $500:000 Maximum Liabiiity�of Insurer Part One: Statutorv Part Two: $500.000 The contract contaius the following conditians: 1) It is understood and agreed that any money received by the Self-Insarer under the , provisions of this contract shall ba deposited in such bank, or with the Treasurer and Receiver General of the Comnnonwealth, as the Department of Industrial Accidents may determine, and.any sach money shall be held in trust far the payment of any ' liabilities incurred by the Self-Insnrer under Chapter 152, General Laws(Ter.Ed.) as amended, and no ase or dispas�tion of any such money sha[1 be made without the approval of said Departmen� IE is further understood that no money shall be assignable or subject to attachment or be liable in any way for the debt of the Self- Insarer unless incurred under said Chapter 152. 2) It is understood and agreed that if any party to this contract desires to cancel this contract, such cancellation shall not become effective fpr a period of at least thirty days following not�ce to the�Department of Industrial Accidents of the Commanwealth of Massachusetts,by registered mail,af seech cancellation. 3) No cocnmutation of any liabil�ty incurred by the Self-Insurer under said Chapter 1.52, during the period this contract is in effect shatl be made without t6e approval of the Department qf Industrial Accidents of the Commonwealth of Massaehusetts. Self Insurer CVS/Caremark Corparation and its subsidiaries By Reinsarer National Union Fire I surance Com an of Pittsbur h PA. � By Joseph A vide, hief Underwrihng Officer '