HomeMy WebLinkAboutApplication and WC � � � • TOWN OF YARMOUTH BOARD OF HEALTH ��b��° i
� � APPLICATION FOR LIC NSE � 5 MAY 16 za15 i
`"°' * Please complete form and attach all '� " s � o De mber 1 S 2014.
Failure to do so will result in ` ret �y�r � tion ac DEPT.
ESTABLISHMENT NAME: " TAX ID:
LOCATION ADDRESS: � TEL.#:S� /S�S� ;
MAILING ADDRESS:_ �q.►o���. _ i
E-MAIL ADDRESS:
OWNER NAME: 2 �' � ��� �
CORPORATION NAME (IF PLICABLE): �'—
MANAGER'S NAME: �' a�. TEL.#: AS `t��f '
MAILING ADDRESS: auc '
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POOL CERTIFICATIONS: ;
The pool supervisor must be certi�ed 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. �
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Pool operators must list a minimum of two employees currently certified in basic water safety, 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. ait�vs,.���� I
�3. � 4. � ;
FOOD PROTECTION MANAGERS - CERTIFICATIONS: i
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. I
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.
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1. 2.
3. 4' 4
RESTAURANT SEATING: TOTAL# �
OFFICE USE ONLY '
LODGING:
LICENSE REQUIRED FEE PERMIT# LICC�I�QUIRED $55 PERMIT# LICMOTELEQUIRED $1 0 PERMIT# �
B&B $55 gg �SWIMMING POOL$110ea��J�
—LODGE $55
=TRAILER PARK $105 _WHIRI-POOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICCONTINENTAL D $35 PE�IT# LICNON P O�FIT�D $30 PE�IT#
0-1 0 0 S E A T S $1 2 5 COMM O N V I C. $6 0 WHOLESALE $g�
>100 SEATS $200 — —RESID.KITCHEN $80
RETAIL SERVICE: VENDING-FOOD $25
LICENSE REQUIRED FEE PERMIT# LICEZ SOoO Qft I�D $28 PE�IT# LICTNOBA�OUI�D$1�0 PE�IT#
<50 sq.ft. $50 — ,=FROZEN DESSERT $40 —
'—<25,000 sq.ft. $150 //Q (�Q
— A��IOUNT DUE _ �
NAME CHANGE: $15 — ORM**'`** �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF F
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� The Commonwealth of Massachusetts
_ Department of Industrial Accidents
Office of Investigations
' I Congress Street, Suite l00
Boston, MA 021I4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: ,� � 2� / i'
Address: 33 G ��ya� ��G
City/State/Zip: 6�� ��//� Phone#: �jj 7,-� `�.���'?
Are you an employer?Check the appropriate bog: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantBar/Eating Esta.blishment
2.�I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto, etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g• ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.� Manufacturing '
no employees. [No workers' comp. insurance required]* 11.❑ ealth Car
4.❑ We are a non-profit organization, sta.ffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12. Other � A�' PGf/I/
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensafion 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#i.
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 ezpiration 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,u�der the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: Date:
Phone#: �C�����' /5�y%j�""
Officia[use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person• Phone#•
www.mass.gov/dia
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CERTIFSCATE DQES NC}T AFFIRMATNEtY OR NEGATNELY A11AEN�, EXTEND OR ALTHt TNE C01tE�iACsE AFFORDED SY�P�WCIE$
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the tettns and conditi011S Of the PoGGY.C2rbin pDliCtes�Y�'eq�fTe an endorseme�A sfat8m9tIL 4n this carti6tAbe does not Confer rights t0 the.
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