HomeMy WebLinkAboutApplication and WCTOWN OF YAfiMOUTH BOARD OF HEALTH
AA=I LOCATION FOR LICE'NSEYJEDER � 4
* Please complete torch. and attach all neces4ary documecits by , e §r . 2 13 I "i L 2013
Failure to da an wiU result in the retl{rn of your applica cote pae et HEALTH DEPT.
I �
NAME OF ESTABLISTIMENT: Dunkin Donuts... TEL. # 508-862-9062
LOCATION ADDRESS: 464 to
MAILING ADDRESS: Stoneham MA 09180
OWNERNAM9: Salyi.CouteTAXID (FEINorSSN):01-0769146
(IF APPLICABLE) !Cape Management Team I I C-
MANAGER'S NAME !?Saxl.lVl + QQ0al d _ TEL. # 781-279-029D
MAILING ADDRESS: 1 R9 Main Strap+ Rfnnahnm MA n91 An
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,.
l . 2.
Pool operators must list a minimum of two empp� g�yees currently certified in basic water safety, standard Fast Aid and
Comtnunity Cardiopulmonary Resuscitation (CPR),_Please list these employees below and attach copies ofenlployee
certifications to this form, The Health Department will not use past years' records. You must provide new
copies and I a :+ale at your place of business_
1. N 2.
= s �i
FOOD PPF '-' aRZ
aim
All food
certified as a Food
Protecticg,,,R r
i05 CMR 590.000.
Please a1 �M a �`'
A.til
ast years' records.
You mega Wit, ar
r
hone, s
PERS
Each , � B/L'E 5 rs of operation.
a trained in the Heimlieh
ig.procedures below and
use past years' records.
y ' �srt s' ENSE REQUIRED FEE PCRMIT tk
$55 _
� 1 �
_SWIMMING Pool. $80ea.
WIi1RLPOOL $80ea. ^v
LICENSM $SQUIRED FEE PERMIT # ,, z,�M r i LICENSE R1 QUIRED PET: PERMIT #€
0-500 SEATS $$5I4-0�- �CONTINBry { sq ' NON -PROFIT $$0
>100 SEATS $160 ,_j_COMMON VIC. $60 I u. HQLESAL E $80
RETAIL, SERVICE: .- .RSID, KITCHEN $80
LICMNSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 0
<50 sq.1t. $50 _>25,000 sq.ft. $225 VENDINO - FOOD $25
i
_<25,000sg1t. $80 ...-..FROUNDESSERX.$40 _._____ TOBACCO $55 _
NAME CHANGE- $15 - AMOUNT DUE _ $ I'-1-5.00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"****
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