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HomeMy WebLinkAboutApplication and WC ����a��� �°c��rt oF��o�rs$4�n+t�� � .�r��+cA�oN Fox�cExsE� �� �-�� DEC � 1 2016 � . '� �r �� - *Please cc�mplete form aad att�ch all ¢ �� � DEPT. �ailure ta do so will r�a1#in the r�_�gro�`� , ��"A� I�1�+iET1T I'�AME; I� U - �AT`T��ADDRR.F.�s: s`[�i- Ro v�E 2 f� W�s7 YARM pr�Fl .,n R TEL.#: 5 o g--�q v- 1 q S� 11��,i�i���RESS:_�9 tf Ra�trf� 2�S Gv�S� Y A R M o vq N r 1�1�2 6�-3 �-�AI�..A��RF�:S�:__�R�i. ,�p�6 o Q IrFo`f M R 1 L-GU Nl t�'�+���vIE; P�e,�+�a �C o M t�r�e.�+A R���r - �t)�t9��"ION NAI�+IE{IF APPLI£ABLEj: �I,A��:�S�.'�1'�A�1/iE; �MO I�AJ p f-f01vC'r`�D NG TEL.#; 5"v�-2�o-ok38' N�Ii. .�DR�S: 2 o w S�t" Ai I i�1 0 2 6 0 �i�'JL '�ICATI�I'�S. Tb�p�i� ' r mu�be�rtifiai as x Poal Oper�.tor,�r�q�ir�d b�S�bi!r+v. Piease list tl�e desi P�i iL� s)��eh a eopy c►f the ceitification to this f�m. l. 2. P�1 � r.�m�t list a minimum of two employ+�es cu�y i�a Fir�t Ai�3 a�d asa�ity Cardi�ax! l�,esuscitatirm {CPR), having one ceitified l�yae� ' at all times. P�se li�t�tlas �q�pl �v and at�ch c+�p�es of th�ir c.ertifit�ti�to this����rm.1'�e �t#�I�rart�+�t���t�e�tsx ��' r�, Y�u mus#pr�vide n�cop�ces nnd m�m#ain��k stt�+�pl��ae af bnsi��. 1. 2. 3, 4, , �����°�T°T��+11�I�IA�ERS-CERTIFICATTONS: . :�il� f�d ' �tabli�hmeuts ar�r�Quired to have at lesst uu� fuli-ta�er�pioy�e�ho is cer���s �Fo�ci � " er,a�defined in the State Sanitary Ccxl�for Fc�od�vi�Fstablishme�ts, 1�S �i�IR 594. . Pl� �rie�of c�rtificalion tc3 ihis applicatian. T7ie H�th D� t�►iIl H�t�se p���'a�u�. ����t�vide�v copir,��n�msist�in a file at yonr� ' �. l, A �IQR Iv PoI�G�o N � , �. PERSfl���HA��3E: F.ach f�d c�abli�hm�nt must hmve at least one Persan In Charg�e(PIC}��iitc during hours of t���n. 1, �bh DRN o�GTDIU G 2. �.,�� ��t�A����; �fc�d ' �stabli.�nents�rie s�qa�ir�ed tu have at l+�ast one fiill ti�e�lo��e�who has All�rge��certi�c�on, ��a�ed iat�e�ttatce Sanitary�aode for Foud Service Es#abiishment�, 105 CIt�L 59U.�9(�G�3��j. i'I� h c�i��f " s�t%an t�this�ppli�atian. T6e H�D�p�ri��n#�a�t o�e g�st ye�er�'re�rda, Yo��a�t p�rov��►�op�es�d m�in#s�ia�Sle st�onr estibl�lum��. �, PR R ��p s�o M k�+�H A lzo �N �. HEi�,i��E�'TT�T�CAT`IQl�tS: All fr,u�d. ' �ablishme�ts with 25 seats or mc�e must l�ve at 1���nnpl�yee trained in the Heiaa�aci� l�r����pr�mi�at all tim�. Plea�e list youremp lr�y� a�auti-cholong pro�eclu�r�below�axi �ch '��empl�y�e��ertifi�c�to this fc�rm. The Heal�h e.�t w�1�t�e past��ra'a�ecorda. ���� s�►e�►pi�a�d�siots�m a f�le s#yonr p��� ' �, PRt����- so�r?�1T�+A �o��v 2. �tp� w� ���T� .���`��Nps��f�EN �. �, ' ���.��s���; To�r�# 3 � �� . o�rc�usE or�.� �� � �� ���� � �� ���� � � �s sss c�n� sss �r�+rn�, s�;o � SSS GA�AP S55 _5WI1►+II+dING PfJOL Sl l�ea. �T.�D(� SS;f ='TRAILER PARK SI�S ��i�Htltl.PUt)L 311{ka. FS?DD LI�� F� PE1tl�lTT' I.I�ISE REQIJfItED FEE AT.R�►+TPI'� LTC�NBE��UIR� � �3�"�k �S1-���A 312i ��„�1 C()NIINEKI'AL �35 TiUN-PItO 33+d >i��►r� xz� _�_____ �cro�orr v�c. s�w ��3 .=-`�o�s� � -- _.�u�.�arrc� � �� L��E�TS���fY�ET) FEE PF.�tMTT'# LICENSE REQUIRED FEE PE�:�fi1"�"� 1.IC�1SE REQUIRED FE� � �SU �. SSt3 >2S,Ob0 8. S28S � �DING-F(?t�l� S2S _�,���. $l5U � _�ROZEN�ESSE$T S4a �'I�BA�G'(? �I l fl �E r^�e�. $i5 ������ = J '"*"«PLEASE Tt1R1V OVER AND tt�MPI.ET�UTHER SID�tDF F{�liM*s*•s � �o�F-is-I Z$?-Q2. i ; AD�STRA'TIO� �i��l�gt�1�2,�i�m 25G,S 'on 6,the Town uf�annouth is�v�r��d#:��id is��a�x or renewal �f� li ,�r p�i�t� a busi�ess if�person or cvmgaay does a�t have a Cer�ifia� af�7'flrlc�r'� �srm��n Tr�t�. TBE A�'I'ACAED STATE �VUItKER'S C�'3i�'�TSATIONt INSU�ANC'E A�'ID,�i3�'�'A+I��'d'�E�COMPI.E'TED AND SIGNED,4It CERT,OF INSIIRAI�iCE ATTACHEi) UR - �� 'S�o�.,�n��►vrr st��.0.��,�r�►c:� � Town c�f� t�c��lien�must be paid prior tc�renewal or iss��f ys�ur p�iRs. PL.EASE�HECI� 11PPRf���IA�'Ei.Y Il�P�: . YES � Nfl 1lVII�3TELS ANTl QTHER LODGiNG EST�3LI�'i�1�T� T�S�1'�1'UC�CtTPAl�C3�: �'or pu�pc�ses s�fthe li�itations c�f Mote�Qr Hot,e1 us�e,Tra�n�a�tt ovaupat�cy s�I�ae limited t4 t�e tern.p�rary�d slwrt t�nm c�cctrpancy,ordina�rily and custom�rily assc►ci�cl�vvi�h motel and�1 a�, 'Tratt�ient �u�auts na�t l� and be able tci clemonstr�ats that tl�y �msintair� a Pz�a� F1�ce o��i�ence slsewhere,Tr��t c�os,�shsil�enertilly neffer to cc►ntinuous ciccupan�y c�f nc�t rn�re (�4�d�.y�,aa� ��gat�e af n,�t m�e�haqn n�etY(40j d�ays within any six{5)morrth per'tQd. 't.J�se ofa wait as a resicl�c�r dwellin��mit sh�ii a�t b��i�t�ansient. Ctcc�cy thax is sub�to�ie�v�le�tion c�f �cupan+cy E�ci�,�de��i i��,G,L,�.64�or$30 CMR 64G,as amended,sha�i��i�b�e s�a '�'ra�si�nt, Ptl►ULS �SI�L�P�1��.All�w�imening,v�ciing aad whirlpools which ba�e bee�cic�f�n�e�n m�be i�� by t�H�h.��t 'or to r�ng. Coniact ttie�-Ie,alth to uhed�t#�e i� ' ��{3j da�a pr�C►r�tr�� �+i TE:People ars I'�C>T allow tr� sit in the pcwl�rea.wrtil �ol h�as been in�p+ect�� I't?C?L�.A��TI11i�G; 1°hc water mnst be te,st�xi for pseudomonas,taji�l�lifc�ma� late c�unt by a �t�e aerti�� 1�, �l �it�t�ed to tlie Healtb Dep�tment thnee �3) �►s �ric�to quarterly there�fter. ' PUUL CL���G,Ev�y in gcx�u�swnmming poc�l must be���r�ven�d�viixhan�ven(7}�s of closing, F4UD SERVit'E ��.St31��!►L F�1}�ERi�I�C'E UI'El'+�IIN{G: All f�d�rYice es�li mast be ins�i by the Hea�#h Deparnn�pr�or tt� . 1'�e ca�t�t the H�a1th T�ep�r#�nt� ule t2te�on three{3)c�ays Prior to op�ung, C'A1T.��+i�PUI.IC�; Anyon� �vho �,a.ters �thin ttre Town of Yarmoutt� must notify the �anmouth He�it�► emt by f�ing t�e x�uir�d T Food 3crvis9e Appli�ation form ?2 hours prior tv � c�� �e�t. f� c� 1� +�btained at the H th �rt,�from the Town's website at www.��t��.us �-Ie�th��t, T�wniQa�bl�e�s�rms, FR4�I3F.��'T'�'►: �r�z�n t�s�ma�st 1�test�d by a State�ertified iab�nivr to�pening a�m�tta��therea#�y e�viith�I�resu�ts �u�mitt�ts��I���Iaep Failure to do sa will�.lt in#he su�ion s�r rev 'on of;your Frozen I��P�#�� c term�ha.ve been met. 4tJ�T�E�'!1►:F�; +�utsid+��af��we.,�uidc�r se�tin,g wi�waiter/waitmss service),must�av�pnt�r app�vsl fr�the of I�ealth UUTD��t����: �utd�r�lcing,�parast%on,��aispl�.y of any food pmduct by a retail c�r fc�d s�ervic��tablgshcaent is proLi6ited. NUTICE:Pernuts rim a�an��ily fma�J�nuazy 1 to De�em�l�r 31. TT IS�'UUR R�SP�1'��BI[.I1'Y T'()��N THE COIVIP'LETED It�'�9VAL APPLICATION{S)AND�tEQUIRED�EEE(S�B��E ER �6,241 b. II' ALL REA�IC3VAfiIfl�TS �'� APl"Y FOUD ESTABLIS�[�+�+IT', IVIflTEI� �R PC�L �(ase., I' Ci, NEW I E�Ui�'l��i',�T�,),��'T°BE I�tEPORTED TO AND APPROVED BY 7'T�E I3t�AR,I)OF "�H PI�3lJK TO G�J���TC�F.,�]EI��. (�iTA'�°IC}AT�MAY�EQUIRE A�TTE PL�I�T. j DA�: � 1 3 0 ��� s�+G�va�+:�: �S % � i �����: ��2� ��� SoM1�ITC�1f� �D�N � J �e�.�orl�a�� � Tll�e�C`ot�sno�ewe�tJ�of Ma��e� Dcprw�rnc�rt a�I�dastri�rl Ac,ci��s (�c af'IR�g��s ' 1 Co�egrr�S�ree�S�c�fJ� Bo�to�MA (1211���11� ' mw�v,�ras�griv/�r �Y��ker�' �rm�ssatioa Ia4ntrou►c� Affi�°�i� Geeersl Bnsinesses ���t I�f�n�slat��t Pl�ce Pr�nt L�ibl�► ���e���r���; �� S i �T��1 �U i S I�v � �d+c��� �`�� �-�1 V�� 2� C���� • : tnrt�s�r ou�� P�o��; ��g�- ��'o � rR��- Ar{e y��a e,� ?��eek t�e aPP�P�te boz: " �`ypc(��� 1,� I�a a�loyer with 3 ,emplo}►ees{full and! 5. []Ret�i1 or " �,� b. Q_ _ _ ' g Fs�tabli�h� 2,� 1�n a ' t�r srr � ip�nd have�o ��. �4�e � or Saie��incL rsal�e,s�,�tc.) �a�r��r�g fur�in�+r,�paccity. a p p��_ s�.�j�(�111� O. ��OI1��['r1� �raiay 3.� �aC a���c��ratit'�ri Snd i1�{?ffiixr+3 hBYC e�CiSOd 9. �]E�► a�ar��f�c�o�per c, 1 sz,�i(4},anat w�have 1 o.L]M� �� .[�o work�s'r.c�mp. ' �l* 1 i.Q i�I�1th� 4.� ��aa���fit Qt��rriz�i+an,�iaffed by vulunteers, 12.�(� wi�a aaa�piaye�es.[No wo��ea.s'c�-insuu�ce I'a4-] ',Aa�a�p}ic��t bamc�1�t a�o fli+ant�e aecdon bdo�w sbawmg�their vv�lce�' ' pvla�ey` ' �`sif�e t�rp�ae�ie l� ix�ti�e caparation Ms otha r�np1oyt�es,a�o�Oats' ' paiicy is reqtricrod mi�dt�t ' ��adc bt�c#]. I�rt trn �ispr�lv�tl�teg luntk�rs'�r.�o�oat�Trrrtae,fOT�sy �is fhePolicj'�' , �I-�-�,DI�+ INSV�AN�� �o�p�Ny �� po_ �ox 5°ft�F3 c���z�; ly,t N A��t� f'� L i 5 � M N �s� S�- o ��c 3 p������-�,��.� M ��� P 3 0 �q�� ���: 0��31 I2 0�� A�� �f�e.�or�rs'c�mp�uu��a�g►a�rsti�P��(s�a�e�t��y n�mb�aaa e�►�a�bc�. Fail�re to �v�rage as respured um�r Se�ion 25A af MGL c. 152 t�a l�d to 31�� ' of cnmi�l � +��a fu�e up�ci�1 .O(?�l�one-ye�r it�xis�rnmeat,as well as�ivii pena�ti�s in tt�e forffi of�S1'4P Wt?�K��ER s�cl a� +�'up to��O�i��y a�iust tl�viola�or. Be aavised�a cx�y of this �ay la�e f�rrw�nded to i��of Inv�ti ' �;f�DIA for�c.crve�age vc�rific�ii�. I do� ,u��e�a�s�p�a.fPa7�3'�tke 6efar�fo�e �i is�rrie mid�cd �.� .���� � I (-- 3o — �or (, �- ���� ������m������a� c��a�.: r��# . �i�A�{�o�e}: 1��ral�t� 2.�l�ep�r�t �CHyt�owa Clerk 4,Lie�as�B��l 3.Selectmen's(� 6,�h�+r ��� �� wwvr.ma�.�rvk1� I�. i ' i 1 ; ��� NOTICE �-,��� .. NOTICE �!� ��.,.,_ ..�3� �o �� ;�� To � �. � EMPLOYEES �� EMPLO�EES �����:x�`�` The Commonwealth of Massachusetts I)EPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2417 � 617-727-4900 —http://www.state.ma.us/dia � As required by Massachusetts General Law, Chapter 152, Sections 21,ZZ &30,this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Acadia fnsurance Company NAME OF INSURANCE COMPANY P.O.Box 59143,Minneapotis,MN 55459-0143 ADDRESS OF 1NSUR.ANCE COMPANY MAARP301949 O7l31/2016 POLICY NUMBER EFFECTIVE DATES Kerry Insurance Agency Inc PO Box 1945 North Eastham,MA 02651 5082558000 NAME OF iNSUR.ANCE AGENT ADDRESS PHONE# PRACHA SOMK{TCHAROEN dba:BASIL THAI CUISINE,594 MAtN STREET,WEST YARMOUTH,MA 02fi73 EMPLOYBR ADDRESS O6/02/2016 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE 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 rnust be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices 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 NAME OF HOSPITAL ADDRESS ' TO BE POSTED BY EMPLOYER ... ,.��� ,�,,..,.