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Home My WebLink AboutApplication and WC J � TOWN OF YARMOUTH BOARD OF HEALTH FR-�`"� � � � APPLICATION FOR LICENSE/PERM T - �' � - � � � R � .�1� I � SS LJ �'" * Please complete form and attach all necess e D� `e�°eber IS 2014 Failure to do so will result in the retutn o � �dEit"a ' i �i packetA�� 1 Q �p�j ESTABLISHMENT NAME: S o u I G TAX ID� - ° '� ��'��1 � LOCATION ADDRESS: �, . ¢.r . o TEL.#:y � � - � MAILING ADDRESS:� �Rca[ G-r r �l n2�7�; E-MAILADDRESS:�4,P r . r��,;�,rY � a�� • �Orv� OWNERNAME:�/.hvrna �� n[�P CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Sc nnP TEL.#: 4� a,n. MAILING ADDRESS: �a n�e 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 Cazdiopulmonary 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 Tle at your place of business. l. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents aze 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 Establistunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wi11 not use past years'records. You must provide new copies and maintain a file at your establishment. 1.��7.1�C1_��Li Yle P . 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. �e-ber �a �u.n�p z. ALLERGEN CERTIFICATIONS: All food service establishments aze 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. v h �� u.-nn 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-chokmg 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 fi►e at your place of business. �. ►� I � - z. 3. 4. RESTAURANT SEATING: TOTAL# C� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $110 —[NN $55 CAMP $55 _SWIMMING POOL$i l0ea LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $ll0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 =��DE CHEN $80 ��P RETAIL SERViCE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25 <25,OOOsq.ft. $150 _FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ IiO '�� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION 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 CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily 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 elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirly(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 are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count 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 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. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so wili result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoar cooking,prepazation,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 I5, 2014. 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. ' DATE: � (� Ib SIGNATURE�_��r�A�,L!� �Q � I PRINT NAME & TITLE: ��CCG �wr�[�� Rev. 11/03/14 t� The Com»zonwealth ofMassachusetts Depariment of Industrial Accidents O�ce oflnvestigations I Congress Street, Suite 100 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Business/Organization Name: Address: D2,lo City/State/Zip: ��--� 0 Phone#: SC� �33 - 3g3 i Are you an employer? Check the appropriate box: Bus,-in,/ess Type(required): 1.❑ I am a employer with employees (full and/ 5• Ll Retail �.,/or part-time).� 6. ❑ Restaurant/Baz/Eating Establishment 2•�J I am a sole proprietor or partnership and have no �, � p�ce and/or Sales(incl.real estaze,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3.❑ We are a corporarion 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]* 11.0 Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compeasation policy information. '*If the cotpornte officers have esanpted themselves,but the coiporation has other employees,a workets'compensation policy is required and such aa organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Be/ow is the policy informntion. 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-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 violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance covemge verification. I do hereby eertify,under the pains and penalties ofperjury that the information provided above is true and correct. �ignature� 9Q-E-c-". � - narP• g I �� c'� Phone# �� _�g� � Officia[use on[y. Do not write in this area,to be comp[eted 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 II Contact Person: Phone#: www.mass.gov/dia � TOWN OF YARMOUTH BOARD OF HEALTH ��'S�C`��DD � � APPLICATION FOR LICENSE/PE -20�5 �Ui�l 's 81015 * Please complete form and attach all ne s�, e �ts �ec mber 15 2014. Failure to do so will result in theE�tui-� �u�p�cAlIon ac ALTH DEPT. ESTABLISHMENT NAME: TAX ID: LOCATION ADDRESS:�4�, ,�r�} UcX,rvia , Qd • UQrM�,�`�t�Qefl c�114TEL.#: �"iQS `]33 -3 S�� MAILING ADDRESS:�'�� '�� c. v��< <l-t,-�,--4 M{R b� L�7�" E-MAILADDRESS:��ance roSnar 1�o AMQ.�� ('o� OWNERNAME:�'�.,�r--..��n � -�+� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: I�e L�vc� �i� n n� TEL.#: Scc,ivmZ a 5 a-�ave MAILING ADDRESS: Scinne r_ S�� h av¢ 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), 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 applica6on. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. �L�e.CCl� 7��,�/� 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1._�P b��i, hl�� 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. � �P •C` �L '��, h rvC> 2. HEIMLICH CERTIFICATIONS: All food service establishxnents 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-chokmg 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. rl��A 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 � MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$110ea LODGE $55 _TRAILERPARK $l05 _WFiIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 � NON-PROFIT $30 —>100 SEATS $200 _COMMON VIC. $60 WHOLESALE �$80 — . �RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT It LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _Q5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ ��:�C� •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM••*** ADMINISTRATION 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 CERT. OF INSURANCE ATTACHED OR ✓ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / yEs � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(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 are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count 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 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 tluee (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Appiication form 72 hours priar to the catered event. These forms can be obtauied at the Health Department,or from the Town's website at www.varmouth.ma.us under Health 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 Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. 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 RE"I'URN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2014. 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. DATE: te I S� ( SIGNATURE: � b�e C - ,�,,�c.P PRINT NAME & TITLE: �e 6P Q C C� i�.c-�c• Rev. ll/03/14 . ��, � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 1 Congress Street, Suite l00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses AAplicant Information Please Print Legiblv Business/Organization Name: O U. l ,�a�� I�e s��P vi�-�-z�; � i�-h e h'1 Address: �J�{� t�Je� Urrmow`-�'� �r^, • City/State/Zip: D Y-� la Phone #: ,�"jDS 7?>�-3 g�v l Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. �Retail or part-rime).* 6. ❑ RestauranUBazBating Establishment 2.� I am a sole proprietor or partnership and have no �, � Office ancUor Sales(incl.real estate,auto, etc.) employees working for me in any capaciTy. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment their right of exemption per c. I 52, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 1 I.❑Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I m�st also fill out the section below showing the'u workers'compensation policy infoimation. **If the corporate officexs have execnpted themselves,but the corporation has other employees,a workecs'compeasation policy is required and such an organi��iion should check box#I. I am an employer that isproviding workers'compensation insurance for my employees. Be[ow is thepo[icy dnformation. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic.# Expiration Date: AttacL a copy of the workers' compensation policy declaration page(showing the policy number and ezpirarion date). Failwe to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penakies 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 violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigations of the DIA for insurance coverage verificarion. I do hereby cert�,under th�e pain�s and pena[ties ofperjury that the informaiion provided above is true and correcG Si�nature• l �e�CP c-� �S��.�� c� Date• � I I `� 12 01 S Phone#: '1�J —� Official use on[y. Do not write in this area,to be completed by city or town officiaC 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