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� � TOWN OF YARMOUTH BOARD OF HEALTH REC
� � APPLICATION FOR LICENSE/PE�IT.� ��?,
..�- � �' � '� 2���
* Please complete form and attach all necessary��cu `' ' I S�1�.
� � Failure to do so will result in the return�f you,��id��orf pack t.
�. � HEALTH DEPT.
� ESTABLISHMENT NAME: � TAX ID: •
LOCATION ADDRESS: e TEL.#: D :� - / �'
MAILING ADDRESS: ' � •
E-MAIL ADDRESS: - (Y► t, � �C�
OWNER NAME:J �
CORPORATION NAME (I APPLICABLE):
MANAGER'S NAME: a � - TEL.#:. �-, �-(.{�
MAILING ADDRESS: � � ` �'1 I 2 � ' •
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 farm.
1.���.��-t� - � - i.�.��- [l�1 �I � - 2.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their 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. �CJ�1� � ���-� '
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 Health Department will not use past years' records.
You must provide new copies and maintain a�le at your establishment.
l. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
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 witl 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 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
l. 2.
3. 4,
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P I #
_B&B $55 CABIN $55 MOTEL $1]0 Z.3 p�>
_INN $55 CAMP $55 �SWIM�VIING POOL$110ea. (, �t
_LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea.y��� 7��38
FOOD SERV[CE:
LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $125 �f�g CONTINENTAL $35 NON-PROFIT $30
_>100 SEATS $200 �COMMON VIC. $60 � =WHOLESALE $80
• —RESID.KITCHEN $80
RETAIL SERVICE: -
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
_<25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $110
NAMECHANGE: $�s � AMOUNT DUE _ $ r� -`�`�-_ �l7
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
` ' 1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
' Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
i -
,
3 Business/Organization Name: ' a GI�`I �d��
? Address: �f'�-(0 - Lvin/Y�1'1 ,,��h,f.(.0 ��,�,�� �
� ,
� City/State/Zip• Phone #: .�p� - �-� -� ��C'}
�
l Are yga an employer? Check the appropriate box: Business Type(required):
I 1.�I am a employer with�employees (full and/ 5. ❑ Retail
{ or part-time).* 6. ❑ RestaurantBar/Eating Establishment
� 2.❑ I am a sole proprietor or partnership and have no �, � O�ce and/or Sales(incl. real estate,auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
: 4.❑ We are a non-profit organizaxion,staffed by volunteers, j
with no employees. [No workers' comp. insurance req.] 12.[�ther �QT�� �'��2
*Any applicant that checks box#1 must aiso fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#l.
�
I am an employer that isproviding workers'compensation i ra e for my employees. Below is thepolicy information.
Insurance Company Name: '
Insurer's Address: ���� ���(��/f,�js,����__ /1,������jj .
���� f�E�
/
City/State/Zip:� P� G�y�(1/ � � �}�(�(,� •
1
Policy#or Self-ins. Lic. #_1 n/I'� — (�'j - �'b(��� r - ��� Expiration Date: � TI1 �
Attach a copy of the workers' compensation policy declaration page(showing the policy number a d ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties 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 staxement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,u er the pains andpenalties o erjury that the information provided above is true and correct.
Si ature: Date: D '
Phone#:
Official use only. Do not write in this area,to be completed by city vr town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office '
6. Other
Contact Person• Phone#•
www.mass.gov/dia ;