HomeMy WebLinkAboutApplications, WC and Licenses n .. / Jf1'�� Y� p o� �a� t ;� i � �.c� I'�J
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o� ,,�: �c TOWN OF YARMOUTH BOA �' LTH �
APPLICATION FOR E . P����t'F 2005 � _�B l 5 2005
,���,r � �� � ,
�� I�� ,»�' �. � DEPT.
* Please complete form and attach all n ;,�ssar�,� �ents by Decemb , .
Fa.ilure to do so will result in the rn of your application packet.
NAME OF ESTABLISHMENT: S' cc a. TEL. # •-
LOCATION ADDRESS: / 9�. cc G � 3
MAILING ADDRESS: ! ` S . GU`. z
OWNER/CORPORATION NAME: `�f� T LQ dQ S
,
MANAGER'S NAME: � c. Q��c,� TEL. #508 5' a
MAILING ADDRESS: . # ` �� �
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 emplo ees 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.
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 Heatth Department will not use past years' records.
You must provide new copies and maintain a fde 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.T`�(x�C S ��cn S GGPD �Pf 2.
HEIlVILICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heirrilich
Maneuver on the premises at a11 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 yonr place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE P�RMIT# LICENSE I2EQiJIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT'#
B&B $50 CABIN $50 MOTEL $50
INN $50 CAMP $50 _SWIlvIlvIING POOL$75ea.
LODGE $50 TRAII.ER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIltED FEE PERMI'P# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT#
�0-100 SEATS $75 ��� _CONTINENTAL $30 NON-PROFIT $25
>100 SEATS $150 COMMON VICT. $50 WHOLESALE $75
RETAIL SERVICE:
LICENSE REQIJIlZED FEE PERNIIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQiJiRED FEE PERMIT#
_<50 sq.ft. $45 _>25,000 sq.ft. $200 _VENDING-FOOD $20
_Q5,000 sq.ft. $75 FROZEN DESSERT $35 �TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ •�
'"""'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""•*"
ADMIIVISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal
of any license or pernut to operate a business if a pErson or company does not have a Certificate of Worker's
Compensa.tion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES t/ NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE CUMPLETED APPLICATYON(S)AND REQUIRED FEE(S)BY DECEMBER 31, 2004.
SEASONAL E STABLI SHMENTS ARE TO CONTACT THE HEALTH DEPAR'TMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL REN4VATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL REGULATIONS
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(�)days of
closing.
FOOD SERVICE
CONSUMER ADVISQRY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES•
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must ha�e prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
r
DATE: 90?�I.S�l dSSIGNATURE:
� PR1NT NAME& TITLE: �Q� �Y D,/�'� TS H I.�� Gl GP �>�I,/v ,
10/22/04
<<
. � �o�S�n1 oc�-5<dx/'�.�y
_- -�---�---_---� The Comnionwealth of Massachusetts �7,�5 d�T r�
-'�- -_-_ Department of Induslrial Accidents /�p; L /�
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2
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� - _- 6/10 Washington Stree� f""Floor
_ �,�f Boston,Mass. 02111
,
Workers'Com�aahoe I,s�uee Affidavit: bu�/E
:,z.. , . wn ��e,. _. �.� leetinexl C tractors
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�itv �t/�n✓t c� state- �� up- oa�� 3 n��,.,e# ,��� ��.�6li��i�
wo,�scte i��rrnu�s�:
❑ I am a lwmeowner performing all w�lc myself. Ptoject Type: ❑New Co�strucli�ORemodel
I am a sole 'etor and have�a�wo ' in an ca ' . ❑Buil ' Addition
�_
, _ �. rt .
❑ I am an e.mployer providing worlcers'compensati�f�my employees wo�cing on this job.
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�:
dtr' dte��k-
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❑ I am a sole p�oprietor,geaerat co��actor,or lomeowa�(circte ou�)and have hired tbe co�ractrns listed below who have
the following workecs'compensation polices:
���:
�:
�; nta�e�F-
,
�
w„ s, p �., ,., �.
�nnaat�e:
�•
cits: oLanc�-
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FaNare b sccQe owerase as req�+ed�tder Satloa MA•f MGL 152 aa lad b IYe ie�p�Ma�f cdwial
pnaNia�f a�e�p a SI,SN.M aadl�
one yan'imprboemeat a��as dvr pmltles ia the brn of a 3T0!WORK ORDER a�d a Aae�CS1M.N a day agaimt�oe. I aadastaad thaR a
ospy ef thia staEemeet may be ferwarded�e the Omce�lav�ffi of flte D1A for average veri�eatlse.
I do berrby cem;fy xnder tGe paUs awd pee�lties of perjxry thet die i�foraKado�provided aboNe is hare aad onn+�ct
�8� Date � „ f J . � ,S^
� l 3 f.� !,� � �s0�" � � � S^�r.�ao?
Prim nazne Phone#
e�ia!au only de aet wrke�this ura te 6e oa�pkted bY dlY si'b�vn s�iai
dty or tewn: p�# ��
❑cgeck if immediah rapeme b rr9� �Sdeet�a s�ffiee
��nl�Deparfi�eet
ce�act person: phwe#; �a'
p�a s�c zoa+?
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TOWN OF YARMOUTH
BOARD OF HEALTH
PERNIIT TO OPERATE A FOOD ESTABLISHIV�NT
PERMIT NUMBER: #OS-158 FEE: $75.00
In accordance with regulations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a pemut is hereby granted to:
Artyom Tshughuryan, 441 Route 28, West Yarmouth, MA
Whose place of business is: Subwav
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31, 2005 BOARD OF HEALTH: L�esr.f'arruss�S. C�''du�ii�s,/l�l.`h. '
n��r��s�t,/�v� /�e��
SEATING:O(Zei'O) Roa�u�. B�iLIIfL� �"+IPl�R
�s�, R.�v
�4� �j���, R./V.
February 15,2005 �
Bruce G.Murphy, ,RS.,CHO
Director of Health
r . 5�gw��Wy
' " ��30� -
�•Yq __...__ _w_�__. . __._,
.o�.-R.� TOWN OF YARMOUTH BOARD O�,�A��3'H ' �`�"�`
r _ _,o ;
�:. ;�s APPLICATION FOR LICF�SE�ERMIT -2004 � t
` i L��:: � � 2003
* Please complete form and attach all neces ary dacuments by Decem er 31, 2003.
Failure to do so will result in the ret �of your application pac ef-iEqL..TH f��pY
NAME OF ESTABLISHMENT: �(� G✓ 7 ZG� l /3 TE # �, 7�s Z�G
LOCATION ADDRESS: ��f f��k�t� S T . YA2NAa�f( t'��- �?�73
�A,ILING ADDRESS: /}-� �Q av�
QWNER/CORPORATION NAME: C�72�S(a/�fc� C.�J . ST'�t1PSor Q�h Scd�jc,✓A� ?_�i l��
A ER'S NAME• t`�S ��� T �e�' 8'L7 3a3�
M�AILING ADDRESS: A,R��'�
POOL CERTIFICATIONS:
The pool supervisor must be certi.fied as a Pool Operator,as required by State law. Please list the clesignated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a rninimum of two employees currently certified in basic water safety, standazd 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' recorc�s. You must
provide new copies and maintain a fite 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, l05 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. C � SYe �s dr� 2
PERSON IN CHARGE:
_ _ _ _ _ _
--
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
�. C r,� S��MP��r� 2 �2 I:MP
�IEIMLICH 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# C�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICGNSE REQIJIRED FEE PERMIT f� L[CENSE REQIJIRED FEE PERMIT#
_B&B $50 _CABIN $50 _MOTEL $50
_INN $50 _CAMP $50 _SWIMMTNG POOL$75ea
_LODGE $50 TRA[LER PARK $50 WHIRLPOOL $75ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT#
I 0-100 SEATS $75 �"O��I,33 _CONTINENTAL $30 NON-PROFIT $25
_>100 SEATS $150 _COMMON VICT. S50 _WHOLESALE $75
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRGD FEE PERMfT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $45 _>25,000 sq.R. $200 VENDING-FOOD $20
�<25,000 sq.ft. $75 _FROZ.EN DF:SSL'RT S35 TOBACCO $25
NAME CHANGE: $10 AMOUNT DUE _ $ 75•Oa
**�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"*
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED
Q$ ✓
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES i�'� NO
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 31, 2003.
SEASONAL ESTABLISHMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7-10
DAYS PRIOR TO OPENING FOR THE SEASON.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
ADDITIONAL F.(:ULATIONS
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening.
POOL WATER TESTING: The water must be testc;d for pseudomonas,total coliform and standard plate count
by a State certified lab, prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in gound swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
CONSUMER ADVISORY:
Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products are required to post
Consumer Advisories.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporaty Food Service Application form 72 hours prior to the catered event. Thses forms can be
obtained at the Health Department.
_ �It�����E�SEI�?���-_ __ _ _ _ _ - _ _ _ _ ___ _ ------------_
_---_ _-- -- -
Fmzen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUT$IDE Cr�F�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),tnust have prior approval from the Boazd of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited.
DATE: !Z�}r�0 3 SIGNATURE: I
PRINT NAME& TITLE: c' �� J � �,�,��-��
10/22/03
.' ' .` �-\
The Co►nmonwealt/r of Massachusetts
� � Department of Industrial.-�ccidents
; olllce oller�stl�sdiis
I � 600 Washington Streel
' -� Bosron,Mass 02111
�'" ��y W'orkers' Compensation Insurance Affidavit
ARnlicant intormation: PleasePRiNT�.7�ia
n�m� C'l 1,Q1�7G��t-f�n i.-� .� �/11/�SU� D��t 1�(/�'W�y
location: �"�/ ./'�� '� S7
�tt� W� `�l�Rl'►Ol,(�k /?'4� C��'7 J ehone q S�a 8 77f �2�_�
� I am a homecwner pert�rming all work myself.
� I am a sole proprieror��,', ha�e no one ��orkin� in am•capacity
[�I am_an employer pro��ding w�orkers� compensation for m�employees w�orking on this job.
comnan�• name: ��A S'r.�$ W}4Y Z �f/3
address: 4"�l !"i� �r/ 1 i
cirv: � '7R tu�ou7H �fi b 2�7 ) phone q• 1`u� �7�� d i ��
J�7 �I,�}iAL F,^c' n N D !�?/t�r t`i�'
insurance co. %�21�N�H�Sr I�ru2�tNcr �9 Gr.%A/CY/ A��y p ;,,i Vp z 4�0 3 o g'
� I am a sole proprietor. :enerai contractor. or homeowner(ci�cle onel and ha�•e hired the contractors listed below ��ho ha�e
the follu��in_ ��orker .ompensation polices:
s4mpanv name•
address
��n'� nhone q•
insurancc co. ,Folicy#
comoanv namr
tdd resr
�� nhoee i�•
insuraes�so. �*
�
Failure to secure covera;e�s requ�red under Secnon 25A of MGL IS2 ea�Ind to tbe ioposidoe o(erio�Mi ptaaitles o(a Ii�e ap to SI¢00.00 a�d/or
one years'imprisonment a�w•ell a�civil penaldea io the form o[a STOP WORK ORDER aad a tiae of SI00.00 a day qaintt ma I a■deraa.d mse a
copy of thy statement may be for.wrded to tht OtTiee of Inve�tigaGon�of t6t DIA for eovera;e veritiatlo�.
/do.hrreby cenif}�under�he pains and ptneltits ojpery'ury thol!ht injornration providtd abovt is dtte and cerrect
Signaturc � �2�3l/o ?
Print name c � s7�/"'�taa' Phone M f U 3' 77 i !'1.��
.. oRcial use only do not»rite in this area to be compieted by eih or town oAfcial
eiry or tow�n: Y�M�IIT$ _ permitAieeese M nBuilding Departmeot
�Lieeesiog Board
�cheek if immediate response is required 261 �Selectmen'�OlTite
�Healt6 Department
contacc person: phonc M;_ �508} 398�2231 est. nOther
.. < �„,
T4WN OF YARMOUTH
BOARD OF HEALTH
PERMIT TO OPERATE A FUOD ESTABLISHMENT
PERMIT NUMBER: #04-133 FEE: $75.00
In accordance with regu1ations promulgated under authority of Chapter 94,Section 305A and Chapter
111,Section 5 of the General Laws,a permit is hereby granted ta
Christopher W. Stimpson, 441 Route 28, West Yarmouth, MA
' Whose place of business is: Subway#26113
Type of business: Food Service
To operate a food establishment in: Town of Yarmouth
Permit expires: December 31. 2004 BOARD oF HEALTH: Be�cj��ci�c _`h. �j'oncP� /l'_`21. '
p/����/� ��/ v� �� ���
SEATING:O(ZeiO) Ko�lL�3►�. di?Lil4IL� Ci�+lAL
� �, R.N.
February 6.2004
ruce G. Murp y, .,CHO
Director of Health