HomeMy WebLinkAboutApplication and WC-li-- [l -1 go
TOWN OF YARM
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHU ETT�
Telephone (508) 398-2231, ext. 1241
Fax (508) 760-3472 1-11'1
Board of
Health
f
Ll! i
Health
Division
Ry
Q a�i
FEE: $80.00 per year 6,4s
COMMISSARY/CATERI T APPLICATION - 2011
Name of Business: Q� y Tax ID FEIN or SS '36&0
��gxu
mv ( )Contact Person:,c(`it i Phone Number: 7 d (®fit'
Mailing AddressL
--
s �► _. _ '�_�% �►I �� �i_ ., I � .,ram �� _ f
List all food suppliers:
Ice obtained from:
for
foods below 45E F or above 140E F:
Describe hand washing facilities/procedures and methods for washing and sanitizing cooking
utensils: r f r
Signature of Applicant:
NOTE: The Yarmouth Board of
Caterers located outside of the Town of Yarmouth must also submit a copy of their current local food service
permit and last inspection report.
All applicable items must be completed in order for your application to be processed.
10/26/10
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
�aNflt�
600 Washington Street, 7`k Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building(Ptumbing/Electrical Contractors
❑ I am a homeowner performing all work myself.
Elam a sole proprietor and have no one working in any capacity.
New Construction
Building Addition
`r • u — l,tupLIV ,t, gcncrar contractor, or nomeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
cOmDxuy same:
address:
city: DllOtle #
insurance co. #
company =me:
address:
city Phone*
InS aece co. #
AtlneNk ad�IftraY stet If aeeoaesr
Failure to wears toveraae as aired ender Section 25A of MGL 152 can lead to the hopesitian of ertmM&I penalties of a clue up to $1,3llOti and/or
one years' Imprisonment as s dvti penalties In the form of a STOr WORK ORDER and a fine of $100.00 a day against me. 1 understand that a
copy of this statement ma f rwarded to the Office of invet�eubas of the D1A for coverage verfflftd n.
709
l do hereby cent urt er I�ie pa s and pens of rjary that the iarforstadott e�T d abuse is true and
cprreqL
Signature %
Date ��! j �j1[l�
Print name Phone # L / (T r O
official use only do not write in this area to or completed by city or town oHlcW
city or town:
permtNiceme It OBniding Department
❑ chedr if immediate response is required [ILIcenting Board
ElSelectmen's Office
contact person ❑Health Dgrartment
(miwd Seat. 2003) phone #; QOther