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HomeMy WebLinkAboutApplication and WCESTABLISHMENT NAME: LOCATION ADDRESS ; f� MAILING ADDRESS:_L7 E-MAIL ADDRESS: ro s h OWNER NAME: CORPORATION NAME (IF MANAGER'S NAME: MAILING ADDRESS: -3,91 POOL CERTIFICA'ryn*TO nn. C 5 kA - 2� U R ?ool Operator, as required by State law. Plea., list the designated fication to this form. 4 6 [� i 2. T 0 Z ployees currently certified in standard First Aid and Community one certified employee on premises at all times. Please list the ° fications to this form. The Health Department will not use past and maintain a file at your place of business. 2. 4. CATIONS: lave at least one full-time employee who is certified as a Foodq nary Code for Food Service Establishments, 105 CMR 590.000. tion. The Health Department will not use past years' records. file at your establishment. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. n 1. EMS 44 L. 14C)2017k 2. cri ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, a as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. 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 Departme -` gill not use past years' records. You must provide new copies and maintain a file at your place of �- 1. - 10�5��, 3. � � �•,�-�i RESTAURANT SEATING: TO4L C, # � ilk LODGING: OFFICES� k LICENSE REQUIRED FEE PERMIT # ENSE REQUIRI _.%�ENSE REQUIRED FEE PERMIT # B&B $55 MOTEL $110 "A INN $55 CAMP _ SWIMMING POOL $110ea 94 _ .ODGE $55 TRAILER PARK _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE P RMIT LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 1 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _ _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: RESID. 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