HomeMy WebLinkAboutApplication and WC RECLiVED
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TOWN OF YARMOUTH BOARD OF„IitfAVI. NOV 1 1019
APPLICATION FOR LICENS .- il
* Please complete form and attach all necessary 't:r =' en , .y I oem >< 1312dEPRT.
Failure to do so will result in the retail of your application packet.
NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15'".
ESTABLISHMENT NAME: r-rnr)1XC� r.r> TAX ID:
LOCATION ADDRESS:EZ3 k 4 TEL.#:(S0,-i>s z, cj 1 p.
MAILING ADDRESS: P.
E-MAIL ADDRESS: t Ij c\.(p a, ve3me.o► •-\-_ n t k
OWNER NAME: 'rnt -• R-rsa l 74,
CORPORATION NAME IF APPLICABLE): .,pct C gip.
MANAGER'S NAME: TEL.#: (Gt)10at,72
MAILING ADDRESS:PCS , -5�0-,'? - ,ITh '
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.
1. 2.
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.
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 file at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation.
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ALLERGEN CERTIFICATIONS: A -.
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 will not use past years' records. You must
provide new copies and maintain a file at your establishment. PS740 2&4315
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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.
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NOTICE NOTICE
TO �j TO
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EMPLOYEES ��� .a
EMPLOYEES
The Commonwealt . of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 I Congress Street, Suite 100, Boston, Massachusetts 02114-2017
. 617-727-4900 -http;//w; .state.nia.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21,22&30,this will give you notice that I (we)
have provided for payment to our injured employees under the above-mentioned chapter by insuring with:
MA Retail.Merchants WC Group Inc.
NAME OF-INSURANCE COMPANY
PO Box 859222-9222,Braintree;MA 02185-0000
ADDRESS OF INSURANCE COMPANY
014005032709119 01/01/19-01/01/20
POLICY NUMBER - EFFECTIVE DATES
Rogers &Gray Insurance Agency,Inc. 434 Route 134, South Dennis, MA 02660 0
NAME OF INSURANCE AGENT ADDRESS PHONE#
Old Yarmouth Inn 223 Route 6A,Main Street,Yamiouthport,MA
02675-0000
EMPLOYER ADDRESS
01/16/2019
EMPLOYER'PLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to
famish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'
Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may
select his or her own physician. The reasonable cost of the services provided by the truing physician will be paid by
the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring
hospital attention,employees are hereby notified that the insurer has arranged for such attention at the
COve c"1.
NAME OF HOSPITAL DRESS
TO BE POSTED BY EMPLOYER