The URL can be used to link to this page

Home My WebLink AboutApplication and WC w T, TOWN OF YARMOUTS B4ARD OF HEAL1'.H :: � n � APPLICATION FOR LTCENSE/PE ,R��'-2010 ,� ��A N � � �U 1 O ' *Please complete form and attach all necessary doc�ients by De�e 0 Utr��:� , Failure to do so will result in the return af y,�a�ar a�3p�ication pac . NAME OF ESTABL�SHMENT: % TEL. # ,��8.�,�f,�ZZ�.. LOCATION ADDRESS: �2 MAILING ADDRESS: S OWNER NAME: D F ar ' CORPORATION NAME (IF APPLICABLE): �� MANAGER'S NAME; C , � L TEL. # �;0�3,,�Z, c f 3ZZ MAILING ADDRESS: s— .,.r�.�...,�.�...�,�..^...�.�..�_..._..��...,_._.�..��_,_., POOL CERTIFICATIONS: The pool sapervisor must be certified as a Pool pperator,�s required by State law. Please list the designated i Paal Operator(s) and attach a co�y of the certification to tlus form. 1 1.��.,,,,_,Ll�„r�' 2. � Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and i Cammwnity Cardiapulmonary Resuscitarion(CPR). Please hst 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. , �• 2. ! � 3• 4. ; � ...._...��.�_....,_..-_�_�� j FOOD PROTECTION�VIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least ane 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 att�ch copies of certification ta this application. The Health DepRrtment will not use past years'records. ' You mnst provide new copies and maintain a file at your establishment. � 1. 2. PERSON IN CHARGE: �acb food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. I 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 erYployees trained in anti-chokin�procedures below and attach copies of employee Certifications to this form. The Health Department will not use past years' records. � You must pravide new copies and maintain a Sle at your place of business. 1. �. 3. 4. RESTAURA,NT SEAZ"ING: TOTAL# LODGING: OFFICE USE ONLY LIC�I�TSE REQUIRED FE� PERMIT# LICENSE REQUIRED �'E$ PERMIT# LICENSE REQUIRED FEE PERMIT# !B&B $55 �CABIN $55 _MOTEL $55 lNN $55 ( CAMP $55 a✓�Q� _„_SWIMNIlNG P�OI, �80ea. �,LODGE $55 _,_,_'TRAILERPARK $105 �WHI$I,POOL �80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED �'£E PERMIT# LICENSE REQUIRED FE� PERMIT# �0-100 SEATS $85 �CONTINENTAL $35 �NON-PROFIT $30 d�� >100 SEATS $160 COMMON VIC. $SO _,___WHOLESALE $80 RETAII,SERVICE: �RESID.KITCHEN �80 LIGENSE R£QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIG�NSE REQUIRED FEE PE1tMIT# `<50 sq.f3. $50 >25,000 sq.R. �225 _VENDIrTG-FOOD $25 ,,^<25,000 sq.8. $80 _,,.FROZ�N DESSERT $40 � TOBACCO NAME CHANGE: $is AMUUNT DUE _ $ SS .o0 "**""PLEASE TURN OVER AND GOMPLETE OTHER SIDE OF FORM**" � I .. Y:. i ` °' ` TOWN OF YARMOUT Y ; �' r�c��D I 1146 ROUTE 28,SOIJTH YARMOIJTH, MAS��US�.�'I'5,�2 51 " ) ` • Telephone(508)398-2231,�tt 2�1� � � � �QN �-�h� ' Fax(508)760-347 :� p' '�' , j �.;;� ,�;��-Y�� HEAL�1_t� �i-��. � APPLICATION FOR A LICENSE TO CONDUCT A �' REC`REATIONAL CAMP FOR CHILDREN (Use b�ck of appHcAtion if additionA!space is neoessary) FEE; �5� (NCW�C-0 1 N O'TtiQ2 Name of Cam . �PPu`°`�00� p• G'�A�� /��ND L)Gff cS��u�r ,��?��'le�J Site Address: �2� �i,vE' ��/��' S�A�ri� /�/�j"�,,� DZ6 ��'` Site Address: Tax ID Number(FEIN or SSl�: �-�'�/(� Type of Camp: Day(less than 24 hrs.)�_ Residential(24 hrs.) HoursofOperation: �A/�'I � �P�'! /�DAlO�� ,�Aiod�r�i f,/'i/,,�..A,,�/ Dates of Operation: Opening:-- !'oI2��/m Closing: �1�y��w;.: i , Name of Camp Owner:__�A,OLs �p�� /`�,,qN/�s ��,�Ct��, �n/�. #Zy� r Office Address: 2�f� Lt/�/[..L�w ,�Tj� 'T �f��..�/'f�¢�� /�'��J- �Z6�j'"� Office Telephone Number: �p j� �b Zs C��2 2 Name of Camp Operator(if differeut): Address: I� Telephone Number: Camp Director:��,��E^/ aaar�s: �Z�N,a�s�,�r�h,�-,��,_��-�-,g-�,.r� �� Age:_�n Z Telephone Nzunber:_�U�� , g//(,o Cow,sework in Camping A�ninistration: ��p��,�� G} �L �v�� fi: �L.. Previous Camp Administration experience:_�� i�� Health Care Consultant: /�,.r�,v�� d y�i� Type of Medical License: A'I� MA License number:_��'j Address:23 F�r��}'.[�'`s�P'�f �, ,�,�rn��,y��Telephone: ��8 1 of 2 i � .. rr ( � Hospital for Emergency Services:__�`qp� C;2� �d5 �T�,�-L � ; ' Heaith Supervisor:�� f3i�+��v � ; Age:� Type of Medical License, Registration or Training: �/� . Swimming Area: Yes_� Na If Yes: Fresh Watsr_�� Ocean Pool CPO i � Specific Onsite Locations: � � � / � Water Quality Testing Performed By: "� Aquatics Director:s;�:,��{..�'�fN��/ /�/1^ �3ft•d B� 4iJA�/c:s�� Submit Certifications: CPR� First Aid�' Water Safety� Other Lifeguazds and Crede�rtials:_11�SA L!�'��U,��,e�°� Watercraf�/Boating Activities: Yes� No Describe:��?� � /1�9�� Food Service: � Is food handles, served or prepared? Yes No� Ta what extent? Snacks Cooked and Served by Staff If cooked onsite,Food Ma�aager(submit copy of ServSafe) Catered if so,by whom? � Is refrigeration available for perishable foods? Yes� No Background Checks: Has the Camp Owner or Directar obtained and reviewed the CORI and SORI of each staff person and volwrteer who may have conta.ct with a camper? Yes No � IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS PRIOR TO OPEMNG TO SCHEDULE AN INSPECTION! THIS I5 MANDATORYS OVEItNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. SIGNED: PRINTED:�� .4 �/.t'�'A1 DATED: / � Q See the nezt page attached for a list of documents that must be completed and submitted before your application cun be fully processed. You are strongly eAcouraged to complete these documents as soon as possible and submit them in advunce. This wilt eapedite the process. °�1� 2 of 2 T � ' s �f��„�'—'� \ . I i. NOTICE N W NOTICE , ,., r � TO W � � TO : � � ' EMPLOYEES � eT EMPLOYEES �� `�� qM S�� The Commonwealth of Massachusetts ' DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 ` 617-727-4900 — http://www.mass.gov/dia As required Uy 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 msuring with: THE TRAVELERS INSURANCE COMPANIES � ; NAME OF INSURANCE COMPANY � P .0. BOX 1 450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (IEUB-4735N67-3-09) 03-31 -Og 'Fd 03-3i-10 POLICY NUM$ER EFFECTIVE DATES � DOWLING & 0 NEIL INS PO BOX 1990 ��— a� HYANNIS MA 026011990 m NAME OF INSURANCE AGENT ADDRESS PHONE# a 0 CAPE COD & ISLANDS COUNG�IL INC 247 WILLOW STREET = BOY SCOUTS OF AMERICA a�� 0 — YARMOUTH PORT � MA 02675 " EMPLOYER ADDRESS a_ o_ " ' o_. EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE N o— 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 , � � �J� �d.t' �,..� ��/y�- �.i� /� ��f lU N E OF HOSPIT DRESS 0003,2 WZOP,�o2 TO BE POSTED BY EMPLOYER