HomeMy WebLinkAboutApplication and WC i
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°� � TOWN OF YAR OUTH Boardof
� a�c�od. �
1146 ROUTE 28, SOUTH YARMOUTH�MASSACHLJSETTS 02 64-24451 �
o...� Telephone(508)398-2231,e�. iaai JE1N 2 2 24�;�n '
Fax(508)760-3472
HEALTH DEPT. '
FEE: � s � _ �.:,.
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COMIVIISSARY/CATERING TEMPORARY FOOD SERVICE APPLICA O 15
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Name of Business: �i�'p,s �/-�a.tCas Tax ID (FEIN or SSI� a 2���25��
ContactPerson:� n9'� QrRouvk'� PhoneNumber: �So41-39�� 03�13
Mailing Address• �7 /11 e�o°f'�.n e, �,ti , , .Zl �v.-eaa�u�° /�/f�- ��6��f
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E-mail Address Q,,u,t,'�c�,l�. p�ii' y'��r o a , �r✓�
Address where food is prepared: ` s i 7—
Method of food transportation: !� 4 D 2 � ✓ a c�
List all food suppliers:
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S 7'� ,S D�dEv �
C�.� v� �2 i
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Ice obtained from:��o,D � S �,Aa ao a
Procedure for keeping potentially hazazdous foods below 45E F or above 140E F:
LUm/� - t w - 2e,�^-� °¢.Jr S��
Describe hand washing facilities/procedures and methods for washing and sanitizing cooking ';
utensils: i
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Signature of Applicant: C�L�v ��—a..�Q� Date:��,c „z a ,20� S
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NOTE: The Yazmouth Boazd of Health must be notified 72 hours prior to service of catered event. '
Caterers located outside of the Town of Yannouth must also submit a copy of their current local food service
permit and last inspection report. 'I
All appGcable items must be completed in order for your appGcation to be processed. �i
uro3iw �
� The Commonwealth ofMassachusetls
Department oflndustrialAccidents
OJface of Investigations
I Congress Street, Suite I00
Boston,MA 02I14-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Leeiblv
Business/Organization Name: �tk�s y3a..Y�es
Address: s`( ,{�T K n P� � .
City/State/Zip: . , aa� Phone #:SflB�-3p�J�- b,3y3
Are you an employer?Check the appropriate bos: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑ RestaurantBaz/Eaiing Establishment
2.[� I am a sole proprietor or partnership and have n� �. � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity. FiA
[No workers' comp.insurance required] g• ❑ Non-profit
3.❑ We are a corpomfion and its officers have exercised 9. ❑ Enter[ainment
their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We aze a non-profit organization,staffed by volunteers, 11.❑ Heakh Caze ,
with no employees. [No workers' comp. insurance req.] 12.0 Other �`e-�+' �w
*Any applicant that checks box#1 must also fill out the secaon below showing their workers'compensatioa poGcy infocmaiion.
**If the corpoxate officers have exempted themselves,but the corporation has other employees,a wotkers'compensation policy is reqaired and such an
organization should che�Jc box#I.
I am an employer thal is providing workers'compensation insurance for my employees. Be[ow is the policy information.
Insurance Company Nazne: if/ /3
Insurer's Address: ` �
CiTy/State/zip: ` � i
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(sLowing the policy namber and eapiration 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 fonvazded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi ,under the pains andpenalties ofperjury that the dnformation provided above is true and correct.
S�ature: � ���D-�2� Date: �.s�2� ,�02 02�/�
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Phone#: '
Offcial use only. Do not write in this area,to be comp[eted by city or town officiaL !
City or Town: Permit/License# I
Issuing Authority(circle one): j
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other I
Contact Person: Phone#: '
www.mass.gov/dia �''�
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