HomeMy WebLinkAboutApplication and WC ����� �_�_. _ ,�.__
� TOWN OF YARMOUTH BOARD OF HEALTH � f��(`� �(� r ti�
� APPLICATION FOR LICENSElPERMIT-2017 � t F�L�`' `� ��i 1 b
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s Ple,ase oomplete frnm and atiach all necessacy documentc by l�3e �nnbbeer 16 2 16 � ,_ -���' '
Failure to do so will result itt the retum of your applicaho" n packet. ��� -- Y
ESTABLISHII4ENT NAME: v - � ., , __ �
IACATION ADDRESS:J�i� � ,N� ,�.f` IKGi � `,�-1 C t r1'lC�;Y+�.._TEL.#: �7�'/- .�f'[: -�i��*��
MAILING ADDRESS;,3 ' ' lu��v ,tyl � Li�,�1 sv�t t� /'�l c� L_�!��
E-MAIL ADDRES�: `•' `, [ f , ,
OWNER NAME: l ►vt ��r�TZ�
CORPORATION NAME(IF,�PLICABLE):
MANAGER'S NAME: JC c��iYr ��C�� TEL.#:
MAII,ING ADDRESS• ��:.�ri�
POOL CERTIFICATIONS: ` ' �
TLe pool sapervisor mnst be certified as a Pool Operator,as reqaired by State law.Ptease list the designated
Pool Operator(s)and attach a copy of the certification to this form.
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Pool operators must list a minimum of two employees cur�nfly cercified in standard First Aid and Community °
Cazdiopulmonazy Resuscitation(CPR),having one certified empbyee on premises at alt times. Please list the
amployees below and attach copies of their oertifications W this fomn.T�e Heaith D�epsrtmest will Bot use past
years'reoords. Yon a�nst provide new eop�s and as�tai■a 5k at yonr place of busineas.
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FOOD PROTECTTON MANAC,ERS-CERTIFICATIONS:
All food service establishments are required to have at least one ful}-rime employee who is cert�ed as a Food
Prot�tion Manager,as c�fined in the State Sanitary Code for Food Service Establishments,105 CMR 590.000.
Please attach copies of certification to this application Ti�e Iiealt6 Depsrtment will not ase past ytsrs'rccords.
Yon m provide new copies aad maintain a 51e at your establishment
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PERSON IN CHARGE:
Each food�establishment must have at least one Persan In Charge(PIC)on site during hours of operation.
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ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who 6as Allergen certification,
as defined in the Srate Sanitary Code for Food 5ervice Establishments,105 CMR 590.009(Gx3xa). Plea�attach
copies of certification to tlus application. T6e Heatth Deparlment will not use past years'records. You mast
�; provide co ies and ' txin a file st yonr establishmenw
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i HEAII�+ILLICH CERTIFiCATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises ai a11 times. Please list your employees trair►ed in anti-cholung procedures below and
attach copies of employ�certifications to this form. T6e Aealth Department will not ase p�st years'records.
You must provide n+ew copies and maintain a file at your place of business.
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RESTAURANT SEA'ITNG: TOTAL#
OFFICE USE ONLY
toncnvc:
L[CENSE REQUIRED FEE PERMtT R LICENSE RF,QUIRED FEE PERMIT M LICENSE REQUIRED FEE PERMiT#
B&B SSS CABIN S55 M07'EL 5110
�NN S55 GAMP SSS _SWIMMING POOL S110ea.
_[.ODGE S55 �['RAII,ERPARK 5105 _WHIRI.POOL S110ea.�
FOOD SERVICE:
LICENSE REQUIRED FEE IT LICENSE REQUiRED FEE PERMIT# LICENSE RE�UIRF,D FEE PERMiT#
�0-100SEA1'S S125=��� —CONTiNENTAL S35 NON-PRO IT S30
>l00 SEATS SZ00 COMMON VIC. S60 —WHOL£SAI,E S80
— —RESID.KI'PCHEN S80
RETAIL SERVICE-
LICENSE REQUIRED FEE PERM17'# LICENSE REQUIRED FEE PERMI'f fl LICENSE REQUIRED FEE PERMIT#
<SOsq.R S50 >25,OD0 R 5285 VENDING-FOOD S25
�<25,OOOsgR S150 �ROT.EN�ESSERT S40 _'I'OBACCO SI10
r�ec�w►vcE: Sts AMOUNT DUE = S 125.00
*:*�•pLEASE TURN OYER AND COMPLETE OTHER SIDE OF FORM*"**
�a�F-f��`r3�7-� (
� The Comnwn►yea[th of Massachusetts
Departmcni of Induslrial Accidents
Offtce of Im►estigations
� I Cangress Stree�Suite 100
Soston;MA 02114-2017
www�r�gov/dia
Workers' Compensa�on Lisurance Affdavit: Genernl Businesses
�alicant Information Please Print Legiblv
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Business/Organization N�me: �(;C�1�l � �5��� � � � -�- ��
Address: �� �' ��' ��v
CitylState/Zip:_��� y .��'' `�ho e�#: � __� 7`��`c���L�+ •����
Are yoa nn e�pioy�?CLeck ffie appropriate boz: Busi�T3'Pe��9ai�)�
1.❑ I azn a ennployer with employees(full and/ S. ❑Retail
�or part-time).* 6. ❑RestaurantlBar/Ea�ing Establishment
2. I am a sole pro�ietor or pacineiship and have no 7. �Q���a/or Sales(incl.r�l estate,suto,etc.)
employees working€or me in any capacity.
[No workers'comp.insw�ance required] 8. ❑Non-grofit
3.❑ We are a carporation and its officers have exercised 9. ❑Ent�rtainment
their right of exemgtion per a 152,§1(4},and we have �p_�����g_
no employces.[No workers'comp.insurance recNired]* 1 L[]Health Care �,,
4.❑ We are a non-profit organixation,staffed hy volunteers,
with no employ�s.[No workers'co�np.insnrance req.J 12.�Other
`AnY applic�t t6at chedcs bwc#1 must aiso filt out the section below showing ti�eir waricas'compeosati�policy inform�ian.
sa���offioras have wcanpted d�selves,Mrt the oocporad�has other e,mployces,a w�r�ers'com�on Poti�Y u�d e�d such�►
otganir�tia►should c�dc bou#l.
I am an emptoyer rhat is pmviding workers'eompensation ln�ranee for my emptoyee� Be[ow is the policy infornnatiori.
Insurance Company Name:
Insurer's Address:
I;� City/State/Zip:
� �
� Policy#or Self-ins.Lic.# Expiration Date:
; Attach a oopy of the workers'compensation policy declaration page(showing the policy nnmber apd expir�ttion date).
i Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to�e imposition of criminal penatties of a
fine up to$I,500.00 and/or one year imprisonment,as well as civil pe.nal�es in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this stateAnent may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerhfy ader tliepains andpenalties ofperjury tleat the informatian provided above is true and correc�
Signature• � �'��� ''�� � 1���� Date' ��.�S���
� rn��#- �"] �7 y- ���C.�-��(�;>
Of'ficia[ase only. Do not write in�is anay w be co�pleted bY ctty or town offrcia[
City or Town• Permitll�ceHse#
Iasaing Autharity(circle one):
1.Board of HeattL 2.Baiidiag Departmeet 3.City/Tovra Ct�k 4.Licensieg Board 5.Selectmen's Office
6.Other
Costact Person• ��ge�
www.m�.gov/dia