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TOWN OF YARMOUTH BOARD OF HEALTH MAR 2 8 2019
APPLICATION FOR LICENSE/PERMIT-2019
* Please complete form and attach all necessary documents by D• „ , 1 'r� :ii.'' PT
NOTE:ALL BUSINESSES WITHLIOUORLICENSES MUST RETURN FO - SBYNO AI t .R1,
Failure to do so will res t in the return of your application pack$t;
ESTABLISHMENT NAME: 1/4.s.,,.t_. i2 o ., ).t-k.i ci,),--s Acre 214-fit'-, M`TAX ID:
LOCATION ADDRESS: i Li.g -Rt✓�e 20 c l< .9-Exil, TEL.#:5'o' 3 q ti yr 4 2-
MAILING ADDRESS: /13 T3 csix,, i 9 I :510 � Y.044-Li-ii c Lcx-14- A4,4 09 t+
E-MAIL ADDRESS:
OWNER NAME:
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: `ra servo.o. r��,1 AT e
TEL. : 4-Zig -Lcit-{ -'7[Y3
MAILING ADDRESS: C3."eax, 9 c;1 p,, ym-�.4 atxr i4 )44 0 2 V.y
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
—____._Pool-Operato-(s)and
1. Oce s r �2 �s� NA , A 02 bib 2.
Pool operators must lista 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. '"t'�e"vim>t� � .,� � �� �,•�-�,�,:-1�
3. 2.
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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 file armour establishment.
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P.O.BOX 791 GW f
SOUTH YARMOUTH,MA 02664DAT&
urs of operation.
tine PAY TO THE----.
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F, ani(ORDER and-a fine
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I i 9 t DOLLARS LJ .
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ple and correct
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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
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ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES 17-
NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use.Transient occupancy snail be Lim,mitedto
tha tPmnnran.•and chart Y�..m nom.+„r,nn+s- .�-'y a,r�t�-.....t ..,.--rl..,,.,..:t.-., -..-•,�*-,.,--._i- »._«_s „_.7 T..,.._t r___�__�
NO Y ---
TICE:Permits run annuall from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATIONS)AND REQUIRED FEE(S)( )BY DECEMBER 15, 2018.
ALL RENOVATIONS TO ANY FOOD OR POOL
(i.e., PAINTING, NEW
ESTABLISHMENT, MOTEL
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
NS MAY RE UIRE A SITE PLAN.
COMMENCEMENT. RENOVATIONS TO DATE: 1D� c_,53j�l '� 201SIGNATURE: C l
NAME&TITLE: d c,�� -�t-� -1 2c �.%r; ��t�S`y`' �a �Z �A
PRINT
Rev.10/23/18
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The Commonwealth of Massachusetts
■
Department of Industrial Accidents
/
'V Office of Investigations
1 Congress Street, Suite 100
Boston, M4 02114-2017
rz��+ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name A>EZX v- `C, r c ss D . S t•5
Address: g
\' ,6Z5: 39q —cY? 4z �c u� i use
City/State/Zip: gGu,-a imSIA- Z.6(f Phone #: 5 O 8—X4"6278 at/la- 6 T
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. 0 Retail
or part-time).* 6. 0 Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, 0 Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. 0 Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 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. .4 We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.LE Other k..10 AA d A-5 6 c .
*Any applicant that checks box#1 must also 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#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi ,under the pains and penalties of perjury that the information provided above is true and correct.
Signature: <e.A.,,z Date:d`11(4/1- ZD/
Phone#: o 6 4 6 7e
Official use only. Do not write in this area,to be completed by city or 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