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Home My WebLink AboutApplication and WC� . a�� TOWN OF YARMOUTH BOARD OF HEAL�'��ry� : �� ,,,,, � �� APPLICATION FOR LICENSE/PERMI'�20�� ` NOV O 8 201 Z * Please complete form and attach all necessary�koeui�ents�by Dece be L2PhTEtEPT. Failure to do so will result in the return of�our`'�pplication pac e . I ESTABLISHMENT NAME:�47e CO d 5�tle r ��q�r TAX ID: � LOCATIONADDRESS: �2� 1�1a;r� S� i2t � ��e4-Uarmw.tl, (11'R U26l1TEL.#: SOk-1"1S�S110 MAILING ADDRESS: ca rnP OWNER NAME: � CORPORATION NAM (IF APPLICABLE): MANAGER'S NAME: U�znu (i�ao �� TEL.#: 9�"1-"i�fr —� �iS�o i MAILING ADDRESS: 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. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. 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. l. ��,an 1 13't do l,� 2. - PFP.�4?z IA:�?FZ-h1�t�'-�: - ----- - - ----- — - - _— -- Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1.�„�nc, a�� L', 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. C1u2�1ra l�ia� l; 2.�p(�.c,��1K. CW iMa 3. 1 4. �J - __ RESTAURANT SEATING: TOTAL# c,10O OFFICE USE ONLY LODGING: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 INN $55 CAMP $55 _SWIMMING POOL $80ea. � � I _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 I >I00SEATS $160 �l�-/�20 I COMMONVIC. $60 ��13 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 I NAME CHANGE: $15 AMOUNT DUE _ $ 220•o0 ***"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r ADMINISTRATION � � i Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR i CERT. OF INSURANCE ATTACHED / � OR / I WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth taxes and liens must be paid pri to renewal or issuance of your permits. PLEASE CHECK . APPROPRIATELY IF PAID: ' YES NO MO'I'ELS`AND�dT�IER LODGING ESTABLISHIVIENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 be , limited to the temporary and short term occupancy,ardinarily and customazily associated with motel and hotel use. ', Transient occupants must have and be able to demonstrate that they maintain a principal place of residence li elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than tUirty(30)days,and ', an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy , Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS ' POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening. PLEASE NOTE:People aze NOT allowed to sit m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count I by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly ' thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. , FOOD SERVICE I SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. I CATERING POLICY: � Anyone who caters within the Town of Yannouth must notify the Yannouth Health Departrnent by filing the I� required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ! obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Hea1th Department, �, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: _ . Outside cafes(i.eyoutdoor seating w�h�ait�rLwaiSr�ss se�vice),mu�t have priQrapprovalfrQmYl�Bnard of�Iealih_ _ OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , l , DATE: 11�3�►Z. SIGNATURE: �� 1u �' � PRIN1'NAME& TITLE: ij✓la�Tr �e.r — Cau3�tu tZ;a c� L� Rev. 10/09/12 f � , I ; � � The Commonwea[th of Massachusetts Deparhnent of Industrial Accidents , � Office oflnvestigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Le¢iblv Business/OrganizationName: ��2 �pd �132� �1��' Address:�a$ SY4�i�'1 � ��a.$ __ __ City/State/Zip: 02�0^1 Phone#:�-'�15-$\\� Are you an employer?Cheek tb,e.,��pro�riate-box: -. - . _. -. �usinass T�pe-Erequfred)= - � 1� I am a employer with `�employees(full and/ 5. ❑ Retail or part-time).* 6. � RestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office andlor Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8� ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufachiring no employees. [No workers' comp. insurance required]* 11.❑Health Caze 4.❑ We aze a non-profit organization,stafFed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *My applicant that checks box#1 must also fill out the section below showing the'v workers'compensation policy infortnation. **If the corpora[e officers have exempted[hemselves,but[he coryomtion 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'compensatian insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: - P��isy-#o�'n'��:#— — - — -£xlmaticn Hate- -- — -- -- Attach a copy of the workers' compensation poGcy declaration page(showing the policy aumber and expiration date). Failure to secure coverage as requued 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-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violatoc Be advised that a copy of this statement may be forwazded to the Office of Invesrigations ofthe DIA forinsurance coverage verification. I do here6y certify,under the pains andpena/ties ofperjury that the tnformatian provided above is true and correct ) i Sie�ature: ��- YJ i G O L 2 Date: lI�� I`.1 Phone#: �i�tC'�`IS-$��17 OfjFcial use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town:�A-!)1v1flU7�1 Permit/License# umg A circle one): 1.Board of Health Building Department 3.CiTylTown Clerk 4.Licensing Board 5. Selectmen's Office . er ContactPersoo: Phone#: b�R-348-�� G �2-�� . . . . . . . � ;�,v�r.mass.gov,�aia � � . . ` � I ; � NOTICE 'I N TO E To , EMPL4YEE5 � EMPLOYEES i � �I The Commo wealth of Massachusetts DEPARTIV�E�T UF I1V"DUSTRIAL ACCIDENTS G00 WaahE��ton Street,Boston,:�IAsaschusetts 02111 i 617-729-4900 As required by Meesechusetls t3�aecal Le'w,Cl�apter 152,9ections 21,22&30, this will give you notice that I(we)have grovided forp�ymeat tc our�a�ured empinyoea�mder the abova mentionod i �ItaPur by in�uimg with: A380CIAtEO I T OF T7 M IN URANCE COMPANY qML pB INBU�ANQ COMPANY I 64 TNI D AVEN P.C1. X 7 U (N TO MA Q1 79 RIBB pF YI'tSC1AANC6 CQMPANY AWC 701 2011 12Jp412011 - 12109 D12 kOLiCY� � EFB�CI7NH AA7&S 200 Unooln Bbest� Untt#001 C T Financ�l servke Co aosron aAa n211 t 1 t �a98e NAM&OF 1N9U'BANCE AGENR' ADDAE99 PNi01V8 Ceue Cod 8uau B��fNt Iru � ��8� W Yermouth.MA 62873 _ RMPLOYLA A�DARBSB i � OJI0712012 EMPLOYER'S WOSI�ElS COMP SA7ION OF'B'iC&A(E8'AIYY) DATE ICAL TREATN1ElYT The abore�amed lwrw�v raqmred eiva af pae�eauai 4ywAa srWny mu af�nd 1n the eaw�se ot eegelaymcn:to lrirnish adequoe tad reaaonaWt LaipftN and ui�aMea in�ctwd�au MW the providom oi tlu Worka�Compenc�tloa Act, a�ef eM BYrn Aepere�Inlurr enpe 9e�Swe ta tnelnJurad�mrloyae. '[!s•empioy..mir,r�dses hir or�w.o�n yny,w.a. The rawaabte eat�tbe w�ww ptv{�Id+d M tlr treatln�phydiaw wUl be pud by 1ha tmar�r>if tM aaemrot ie Reeawry sna rwwnahly eonnee�d ta elr wark datad ioJury. Tn cua nqWAn`hotpipl atuaq�,adpioyoe�are bmreby m8rtetl tN+t tfie tnwe�r hu rrran�d tar sacn att� tlon rt t6e ti��eC3T AND 9E3T MEDICAI.R I iTY na�oc o�xosr�xn:, , �►t�rn�css '�Q BE P�'1STED BY EMPLOYER � � •� nccc �c�: a9NtlNOSN1 (!3.iN':;?7SSV P1a'4l �l! ZEOG Y ��b'Yk