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� � TOWN OF YARMOUTH BOARD OF HEALTH �(��[��d
� � APPLICATION FOR LICENSE 2 ..eY �,
�� * Please complete form and attach all necess ��b ^ o �` t ��nberT5�28�11
Failure to do so will result in the retu�of your applicatio pa , �TH DEPT.
ESTABLISHMENT NAME: CQ P e (�o� '�T TAX ID: � - '
LOCATION ADDRES S: y>� r►�r� a S�'n e�t TEL.#: �`��' � 7���o? �G
MAILING ADDRESS:
OWNER NAME: `�oc K-s, 2a< < � �t,��S ,
CORPORATION NAME(IF APPLICABLE):
MANAGER'SNAME: >�^-�- SwnR-+Z TEL.#: So�- 3c.�_&72.- '
MAII.ING ADDRESS: �o > �4ea.sn Nt Pr,�e S /o��e n:e�ufip2v �t 1 e n.t Ct ��t� Z--
POOL CERTIFICATIONS: '
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �'
Pool O erator(s) and attach a copy of the certi�cation to this farm. '
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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.
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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. � SS r 2.
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PERSON IN C�.AR:C_iE: _ _--- ---- -__- ------_. _ ___ _ _ _ __ _--- _ _ _ _ __ ;
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Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
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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 certi�cations 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. '
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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 '��Z"�3
_INN $55 _CAIv1P $�5 �s��t1�1�'vGYooL �8�iea. ��tL b�Z�i2-0��3
_LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $80ea. �'IZ-0 ZU
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ;
�0-100 SEATS $85 ��6 _CONTINENTAL $35 _NON-PROFIT $30 !
_>100 SEATS $160 �COMMON VIC. $60 3'd6a _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
_Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $is AMOUNT DUE _ $ S2o,o0
*****PLEASE TURN OVER AND CONIPLETE OTHER SIDE OF FORM*****
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,�r��$,2011 CHARTI S
THE POINT INC/DOCKSIDE HOTEL
476 MAIN ST
WEST YARMOUTH, MR 02673
RE: Workers' Compensation State Posting Notices and Claims Reporting Information
[To be posted in each lacation]
• Policy#: WC 051-75-0560
• Policy Effective Date: 04/01/2011
To Our Valued Policyholder: ,
Your Workers' Compensation insurance policy has been delivered to your broker, KEATING GROUP OF MA
LLC. Your broker will forward the policy documents to your office.
Enclosed for each location listed on your policy is one copy of the required state posting notice(s) and claims
contact information. As mandated by the State, please ensure the corresponding state notices are posted
in a prominent place at each of the covered locations on this policy.
The states/locations included on your policy are:
State Number of Locations
MA 10
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