HomeMy WebLinkAboutApp, WC & License The Commonwealth of Massachusetts Fee
Town of Yarmouth $150.00
Food Establishment License
Number: BOHF-15-1750-05 Issue Date: 1/1/2021
Mailing Address: Location Address:
MISBAH INC. 182 OLD TOWNHOUSE RD
QUICK MART SOUTH YARMOUTH, MA 02664
182 B OLD TOWNHOUSE ROAD
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2021 LICENSE
TO OPERATE:
Retail;
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2021 unless sooner suspended or revoked and is not
transferable.
Conditions
RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
ruce G. Murph , MPH, ' ., C- • /Mallory R. Langler, R.S.
Health Director/Assistant Health Director
The Commonwealth of Massachusetts Fee
Town of Yarmouth $110.00
Tobacco Product Sales License
Number: BOHTP-15-1751-05 Issue Date: 1/1/2021
Mailing Address: Location Address:
MISBAH INC. 182 OLD TOWNHOUSE RD
QUICK MART SOUTH YARMOUTH, MA 02664
182 B OLD TOWNHOUSE ROAD
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2021 LICENSE
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2021 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston .
Aul —
B uce G. Murphy, M' , R.S., CHO 17-ry R. Langler, R.S.
Health Director/Assistant Health Director
The Commonwealth of Massachusetts
Department of Industrial Accidents
t' :—grit Office of Investigations
�` _•= = v 1 Congress Street, Suite 100
f Vw:7 p Boston, MA 02114-2017
r -
4= a..„z www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: I6(3 f C 3M h;01 1-1Z!.
Address: )8 ) 3 Do)
City/State/Zip: <,; -'14 '441.fri v E7 t�, -'f Phone #: f;OS- � ;�.�
Are you an employer? Check the appropriate box: Business Type(required): I
1.r_:, I am a employer with_ employees (full and/ 5. M Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
8. Non-profit
[No workers' comp. insurance required]
3.L We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]*
11.0 Health Care
4.17 We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*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: ON)0 s (/0 1C— --"N r)14 \) ;v k,P'4
Insurer's Address: a `'' t j
City/State/Zip: _t`V ' k)g4(`) ")A 0 {8 4 - (7 f Li
_ Z'`�'
Policy # or Self-ins. L,ic. # 1.(07 /'�I� 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 certify, under the pains and penalties of perjury that the information provided above is true and correct.
Si• ature:
r1�n ., i ` Date: 3-7
ai
Phone#: -945) ' JLC ` ' .3
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.eov/dia
akI`CK t..
TOWN OF YARMOUTH BOARD OF HEALTH
r Gi y1q
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' %.\ APPLICATION FOR LICENSE/PERMIT - 2021
* Please complete form and attach all necessary documents by December 18, 2020.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME:N?? pi-/ /233Q 01e_k_ M '1/2m' TAX ID: � ��
LOCATION ADDRESS: /8),B 7 r c TEL.#:Si?e
MAILING ADDRESS: /R y e v�7 ,�,� /* &)4 a 7 S >J7� yrz'p fr ' pi
E-MAIL ADDRESS: mo). 4v71i 1 rersr T-
OWNER
OWNER NAME: MU NFi-o)ahik1.3 ..�}+
CORPORATION NAME (IF APPLICABLE): A)i Q3 /1\) )1 ( k))Uz- iv)►i2(
MANAGER'S NAME: i) '1Ornl m TEL.#: 5 , /9(5--
MAILING
9(5--MAILING ADDRESS: 2 1 5 .r 5 c #l'-+JNLc P1 P -)
POOL CERTIFICATIONS:
--the pool superv' as-a Illi it Operator;asi equii ed by-State-taw: Please list the designated-
Pool Operator(s) and attach a copy of the certification to this fonm.
1. 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 nsrpast years' records.
You must provide new copies and maintain a file at your establishment.
J4 2021
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
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.
1. 2.
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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
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