HomeMy WebLinkAboutApplication and WC 4.11% TOWN OF YARMOUTH BOARD OF HEALTHAR.'-
APPLICATION FORLL -2019 i q ,#
�'.-` ' .ls ,1 ch all doamvee s
�Ti1iBi'
!;',1 is*.
Fallow to do so will ram tae rases oryour application packet. 1
ESTABL SHMEN'NAME: 1iti 1io a 4r ii 1�I t7E/ t ID,
•LOCATION ADDRESS:-.3 7 „?.,/ dP \Ii1/Q�e R� Tim . c d 1 �,6
MAI II G ADDRESt 7jP
E-MAIL ADDRESS: I/?r ' /0 enav/.#Cil
OWNER NAME: (i i, /.4 1- pipi,,,.../- . 1--/ -,,-.7.-
CORPORATIOls1NAME 3 APPLICABLE): i7 , • -, , ' .- -. /1, �/
MANAGER'S NAME: .0 . . .�, -r_ I,:+ , i,� .r
M, ADDRESS: .'q 9 _ Vi//7i. 7erf A,,7 01.� .. Aor
. POOL CERTIFICATIONS:
Pool O sa�or(
d supervisor
sj attach certified as a Peel Opera,as required by She Lew.Please list the designated
copy of the coon to this farm.�-�
1. r///a/yl
P/—/ t 2. Mtiftmss CI, /-/a -7'
Pool opeiato s must list a min' bum of two employees taen+edly certified in standard Fust Aid and Community
Cardiopulmonary Resuscitation(CPR),having ens certified employee on at all tines. Please list the
employees below and attach copies of mons to this form.The Del Nass t will not we pat
years records. You must provide new copies and asidutahr a file at your place of basiness.
12 //I ti'h/ ...� '7 2. `eV `/ a PT = a 2
3 r/t y res/ // 4. r Xj �I
l
FOOD PROTECTION MANAGERS-CERTIFICATIONS: o (..,1
All food service ate requited to have at least one Ball-time employee who is certified as a Food ICS I
Protection Manager,as defined in the State Salim Code for Food Service Establislmaemts,105 CMR 590.000. - --i co L')
Please Y a otaerti� o
etintothisappEc �an.TheHeaDepartmestwmuetusepasty�ears'records.
copies mud Rudntain a Ms at your establishment.
1. 2. .
PERSON IN CHARGE:
t all
Each food establishment moat love at last one Person In Charge(FTC)on site dura hours of operation. TO
1. 2. 41
t,,,
ALLERGEN CERTIFICATIONS: .
All food service establishments are requited tohave atleast one thll-time employee who has Allerganoatibion,
as defined inthe State Sanitary Code for Food Service Establishments,105 CMR S90009(0X3Xa).Please attach
copies ofeatification to fide application. The Health Deportment will net ue past years'records. You oust '
provide new eepiU ani mai=m-a me at your estahMainotek
1. 2.
HEDALICH CERTIFICATIONS:
All food service establishmetts with 25 seats or more must have at least one employee trained in the Heimlich
Monomer on tate premises at all times. Please list your goyloyaes trained in procedures below and
attach copies of employee oatiftaticu to this form. The Department w®not use past years'recalls.
Yea suet provida new copies and maluab a Me at your pkg.
1. • 2.
3. • 4. '
RESTAURANT SEATING: TOTAL#. tat trig-04220-06
°mat t Ul E ONLY $a)Nf-1't-o't3?rcf 6-
113111=441
UCIINSERSQUIRED FEB maser. LICENSE UWmm) PEE PER1an4
B&B CA824 0e3
REQUIRED Pl3B
--INN CAMP - SWINININO no
L01>a PARK APOOi 11110.2.
asP__.... s 1 IeR par seict,e R 11�RtiD Pea PI PN
COWAN VIC ago --WHOLESALE I
EMAIL MI=
URD PEE 1 LItT! REQtIRED P13R1QTte NB PBRMPft (I
X3.000 -F000 SO
s tf tt5eSS° $285 _''1OBA 6 $110
NAIMI CBANGZ: $15 AMOUNT DUE - 0' .Ob
•
ADMBEE TRATlON
Under Chapter 152,Seotion25C SubseodaM501110Town W14=0116 is now soothed tobold isawnces orrenewal
of any Rome or parses to opetdete a MINN if a Orriao.ear cony does not hawsIe.0 100 olte of Walter's
Conyensation Lmatanoo- THR ATT STA 'S COMMIStt 6
w
• CERT.OF INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVTI`wow AND ATTACHED
•
Town ofYa noutbt tastes aad'BOOS mmR be peidprior to ranswr l or issuance afycur peaks. PLEASE CHECK
APPROPRIATY IF PAID:
t
YES
NO •
MOTELS AND OTHER LODGING ESTABLISHMENTS
•
TRAPREENTOCCUPANCY:For pe:poses:Abe Bodied=ofMotslorHoMtaus,TransiastaowQesoysbsgbeliiledto
the magma sadshoeless occupancy,radiology and customarily awochtedwide motel and hoed use.1 - .c:eepssee
ant have and be able to dsaeoaetrais that they mainMsi apdwipsl pins of residaros eieesrhera.Transient ossepsaoy aka
generally wise*aoslinnose ooapsocyofactmotethennthirty00)dgs,and:afpepletenetssoeslirasniasly( days
wiri airy six(6)hems&paiod. Use of a guest trait as a resides m or deeellthg soda sher2,not be ocaeidered tnwaierst.
Occupancy that is melded to to collection of Foam Oaoapancy Jam,as defined in M.O.L.c.644 or Ifs CMR 6443,as
amended,shall bo considered Tismiaet.
POOLS
POOL OPENING:Ail sw im:min& aad whidpooie have been closed for the moon maw be by die
Herib Dapeatarseet to opst �t the Health to schedule the i iaaNess dares �s prier to
ereois&Pl$!! People nee NOT slowed to sit in the pool area ad the pool hes been Meowed and-peered.
POOL WATER TSG: The water must betested ir ---cease,toad celibate and stmedesdpiescount by*Stain
-settled Irby and submined to the limits Department these )dips prior to aped,aedquaAa salter:
•
POOL CLOS1NG Sway outdoor Ix ciad, -&my owdoor in paned swimming pool must be drainedorcoveredWithisews(7)clo s dolman&
FOOD HatVIG'E
SIMIK NAL FOOD iilcRYKE OPEirIiNGe
All hod service madditheasals most be hapectsd by the Health Depart:uat prier to*peaie&. Flews contact the Noah
Depsehso**sheikh the iris*ma IW$$int t °penis.
CATERING P CYs
Anyone who cairn within the Town of Yarawats most-achy the Yammer*Health Dspsrt nest the swiped
Temporary Food Stoke Apps -tion than 72 hears prior to the accrued ewear, These hems nes be at the Heidi
Depaeaasat,or from the Tow 's while at rogygmiegmug mderlhalth Depwanent, ► -Forest.
F
Pram
adessaeltaastbaleada codifiedtate rovocatioa of your• to HefR Departtat, Fibre to d.so will matthe or Frown t the
shove tams have been ad.
oval's mita
Oe ssio alai(3.s.,oeMds.r smiths with wahertwalwas service),meet have prior*peeved 11.the&mad of lhdtt.
OUTDOOR COOKING:
Outdoor cookie&pagination,or dirpi►of any lad product by a Mail or hod service atabliethoent is pehirited.
TOBACCO PRODUCT i 'i'CAP
A tobacco paw holder who has failed to renew his or her permit y(30)(lays of the previous year's
permit expiation date is considered an expired Haeme,sed the tobacco license cap is reduced.
NOTICE,:Peimitsrun muskfrom January 1toDeeomba31.f.ISYOUR ItZIMPONSIBILTIT TO RETURN
THE COMPLETED RENEWAL APPLICATIONS)AND REQUIRED FEES)BY DECEIAN3It 13,201$. I
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.o.,PAINTING,NEW
EQUIPMENT,ETC.).MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH MK*
TO . RENOVATIONS MAY -A SMT-PLAN. I
f/
DATE: �/ l/ ! � SKINATtJRE: [1I 1/
PRNNTNAME-&TTI E. P�IE�IG/ , 1�Qh7� ' . P </ k-
s r.1043l15 J
-Shlre
;... .., `� �
• 22P NWC10
il
Peliemy Itienn Psf+s •
. jlJ* .Zarur sd amd Ad+drws -
PM.Blo - .d �. iCY .
S'ft.YhA COMPANY INSCIRA
rA VINM9.'crwww►i • 500,Eaunce Corner If ,
P.O.Box 39 - • - 15_100.S.120
Eh Yoitriouth rr ti`ib4
bartrr►outh,MA 02747 .
-AgeOct CoderMA5YWIO -
- - :00010ysr"ri 2p" Insured Corporation.
Additional.14 N of.Inswwrd:
• (N2y$00-;OGraMMotOS
-
(12) 3347 ide Viliepe.Rd,°Yar'mouth MA 02
(061 i/20i8 06/29/201By
£2]_ `
June 29,20188 tet:June 29;4019,4214 AM„standard time at thea Inaursd's
maib0,0
•
::•
A. iorkett 'Conn ii Don Ileuratrae-ih�rt of thid
s-policy es to the Workers'.Comp s
t,aw of.the( eine'e4tetteOs:Masseehisett --
- 'B. EmploC33Ayer's Uab *y Insurance* Ne 1100 of this:pol cy'applies to-work Inane*:of the skates listed
In item : limits of our liob v under Past` rro are: - 1
Rojo*by Accidenteach accident $100,000
i Injury byr Diseases each er y.+ $1. ,0011 r.
BOW r1W:004105e'r'l P011010#*7- 1:
.. .
- CO -Other States l ante Part Three of this opcyr:�sppi es to atl status,ea pt any listed in
C27A•art�h U*st .oft4orh Dakeat -0 do,iitiitshlnpton,andWYominy - •
-
t?. This p ct includes theseendorsem e .end*th dales. • . -
• See Exclusion of Information Pope-Se duh of Forme
C#] Premium
- The-Premium 0001sand,therefore,t p lum rel be-dote pined by our Maul of Rum.,
'ass1110.00: ,ltd.:ewnd i Mg Plans• _Mt reqs Information is subjeCt to vedfcatlan and chansurhy
-: iit. trrrtttirtiei i.ott:,tioe ser'
•
Total $ 1
Tectal.akerd0trrdesF. ittr! r 10110- 44.00-- • -
Totollothoitod:r -. : - 1,43 00
MGA is 2zitt • -i.- - .htbreeesthrre pwe�yes
bits :cs/J51201s MANOTE
WC.00Ob01A
teeming ohifers:P.Os seat A'*1,set B.*MO Strait,WMktorire4 tW/00461O2Q.WW aimotd.com
1. The Coate et ewn1Ar ofileeseekseeetts
D q)ael sere 'die Acerfdhoerts
' ofhaveselgteleas
, I ie 100
- `1A 02114-2017.
wwirtiawoaegvrta
Wim'Crier Ali avit General Bushman'
1 1kant lel'ormatim Please F.rlat
Busiaess cation Name if. a ✓t ,.. ar' Allor
Address:3 Se5ets/de Vi//effefrm 'tW 11 '1
City/Ste/Z : ar au i A 4 0:. 3-0 9 7( �l' /�
, 7
Are year an ampbyer? the appropriate bac Bisbee Type(
1•I I am a enaployer with ? employees(toll and/ S. E React
or Vie).• 6. 0 RestaurantfilmiBming Eetabhshaeent
2.Li I arc a aolreprepri•for or PutnershiPslid have no ?, p office andbc sus(fid.reale*nate,auto,ale.)employees worldng for me in any capacity.
wodLen'comp.insurance vectuh'ecri
3.❑ We me a corporation and lb officers have exercised 9. Q Entatlimuint
their right of exeraption per e.152,11(4),and we have ion bianufkouxing
no employees.[No workers'con .ima mse re ed)+ 11:Q Health care
4.❑ We an)a or is tioc,steed by�, ,.. ..--y-whh no employees.[No workers'cowl e.aereq.j 12.(,$1 Other !f2 O! e-
*Asyappiiorntt ed ab box 4,1 meth theta the the notion below A l..Arkm s'thopersedat sag fehrie hoe.
'Vibeecalm*oMaws byte= ar,but isnepaasioairlrdale petpio5ssR1elates'aaoupoe-apokyisamibedaodoctan
eripedwdeasbeeddied:boxil. i
Imo et arbiter esattvport**wasters'ew jb'alp tripleyttes. Below iills"eft i
Imm mce Convanyy haat= 0 -.6. • /114 c4cc f"- " / 00f• . "-AlI
Imurees Address: p & / o x A 147' iG A<Yep' S�
► : 0v/l/60,5-• 1-1-"C Pier /8 7 ,3 -- D"a2.
F
Polley 1 or Seelf-ins.Lic.6 ?/ Th2(g 1() D e: o '_l Z/
Attach a copy of workers' palmy page(showing the policy unbar da
Failure to secure coverage as visioned under Section 2SA etWIL e.132 cat lead to the i poehiarr claiming" of a
thie up to$1,500.00 andbr ase.year brpaisomnent,as well as civil peva in the lam oft STOP WORK ORDER aid a line
of up to 8250.00 a dry apinst the violator. Be advised that a copy oft may be forwarded to the Office of
lavestigelione oftbe DIA br bemoan coverage
I4i*meiyits*,depaha sold Adisofigedroilset theIlei nialtis.parrid*,above b tones ad
Ibmggre - WaY1.-21" Date //////9'
7,
./.0,
4014E1 sae sod?. D not wear# reras,AP be coripletedIs0tA or e qpkkd
City er Towns Permit/t±eeerae a
beams Authority(circle Geek
L Beard otHegel 2.Be Deper eat 2 Crews Clerk 4 Mensiag Board S.Sai elmea's Office
6.Other
Conal Person: Phone S:
.w w.womsowes