HomeMy WebLinkAboutApplication and WC °' TOWN OF YARMOUTH BOARD OF HEALTH °
� � APPLICATION FOR T,IGENS r-zoi� SEP 112015
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`" $ Please complete form and attach all n �
Failure to do so will result in the re ` of ura�fp�i on PT.
ESTABLISHIvIENTNAIvTE• ��5 �:�er acl.-t- �'l,i�l Th� T'AXID-
LOCATTON ADDRESS: .�;� �"ra7-�, .�n nam (�,� TEL#• �08 ��'�9 7o t
MAILING ADDRESS: �n �x �s7�� '�.. �/r,r�r�t1'L� � S11 r`� G�/�d�
E-MAIL ADDRESS_ }n-�'� a h�=c .ri v �C �rc�
OWNERNAME: rr1Q�„ A,�rs
CORPORAITON NAM�(IF APPLICABLE): �sS f�.vEr��c_1��T�� b .�i,c -
NIANAGER'S NAME: ; . ' a r TEL.#: P�S'--3R� - " g
MAILING ADDRESS: � j f�ciEs, fY1 t� C�(oo
POOL CERTIFICATIONS: �
The pno!supervisor mnst be certified as a Puol Operator,as required by State law. Please list the designated
Pool Operatoz(s) and atiach a copy of the certiftc3tion to this form.
1. !Y o i�cc�� � 2.
Fool opeiators must flst a**+;n;mum of two emplo ees cutrently certified in basic water safety,stand�d�'ust Aid
and Cammunity Cazdiopulmonary Resuscitation�CPR�, having one certlfied employee on premises at all times.
PIease list the employees below and attach copies of#heu certificauons to t�is form.The Heatth Aepartmentwill
not use pasY yeais' records. You must provide new capies and maintaiun a file at your place of busmess.
L 2.
3. 4.
FOOD PROTECTTON MANAGERS - CERTiFICATIONS:
All food service estabiishments are required to have at least one full-time employee who is cerfified as a Eood
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to ttus applicafion. The HeaIth Department will not use pastyears'records.
You mnst provide ne�v copies and maintain a file at yonr establishment.
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PERS�IV IIV��F�i�tfiEY _ — � —, ��-._____.. _ _
Each food establishnnent must have at least one Person In Charge(PIC)on site during hours of operation
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AT.i•E12GEN CERTIFICATIONS:
All food service establishmeats aze reguired to have atleast 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-atyonr'establishment. �-r� �
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HEA�ILICH CERTIFICATIONS:
All food service establishments with 25 seats or more muSt have at least one employee trained in the Heimlieh
Maneuver on the premises at all times. Please list your ee�baaploqe�s trained in anti-choking proced�u+es below and
attach copies of enaployee certificarions to this form. The Health Department w�71 not use past years' records.
Yom m�st provide new copies and maintain a file at your place of business.
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nneTnrronrrreFeTrnTr.• TnTer `� ln�;
ADMIlVISTRATION
Under Chapter 152,Section25C,Subsection 6,the Towr►of Yarmouth is now re,quired to hold issuance or ren
of any license or permit to operate a business if a
person or company does nc>t have a Certificate of Worlcer'
Compensation Insurau�e. TH� ATi'AC�IED STAT� yVORi�i R'S COMPEI�ISA:TIQN INSURAI�TCE
AFT�'Ib�VIT MUST BE COMPLETED AND SIGNED;OR
CERT. OF IIVSURANCE ATTACI�D
O,K
WORKER'S COMP. AFFII�AVTT SIGNED AND ATTAC�ED �
Town of Yarmouth taaces and Liens must be paid prior to renewal or issuance of your perrni{$. PT.FASE CHECK
APPROPRTATELY IF PAID:
YES v'" Np
• 1�TOTELS AND OTI�P.LUDGING ESTABI:�SIi11�NT5
TRANSIENT OCCUPANCY: For purposesof the�imitations of Motel or Hotel use,Traz�sient occupancy shati be
limited to the temporuy and short term occupancy,orainaziiy and customarily assocfated with motel and hotel use.
Transient occupants must have and be able to demoxishate that they maintain a principal p2ace of residenee
elsewhere.Transient occupancy shall generally refier to continuous occupancy ofnot more than thir[y C3�)daYs>and
an aggregate of notmore tban ninety{9D)days witirin aay six(6)month period. Use of a guest unit as a residence or
dwelling unit shail not be considered transient. Occupancy that is subject to the collection of Itoom Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, s1�all generaily be considered Transient
POOLS
POOL OPENING:All swimming,w,aaing ang�1pools wluch have been closed.forfke seasoa tnust be inspected
by the Health Aeparhnent prior xo opening. Contact the Health Department to schednle the inspectiun three(3)
days prior to opening. PLEASE NOTE: people are NOT allowed to sit in the pool area until ttie pool has been
inspected and opened.
POOL WATER TES',l'Il�TG: The water must be tested for pseudomonas;tiotal roliform and s�da�P�t���t
by a State certified lab, and submitted to the Health Departrnent three (3) days prior to opening, and quarte�.ly
thereafter.
�'aC)L�LV S�'G:Every-outdoor in ground swimming pool must be drained or covered within seven(�)ct�,,-s ef
closing.
FOOD SERVIC'E
5EASONAL FOOD SER't�IC'E OPENTNG;
��fo�od�e mce establishments must be inspected by the Iiealth Department prior to opening. please con��e
paztment to schedule the inspecdon three(3)days prior to opening.
CATERING POLICY:
Anyone who cateis within the Town of Xazmouth must notify the Yaruxoudh Health .
reqwired Tempo Food Service Application form 72 hours prior to the catered event�p T'�h��e o���e
obtamed at the H�th Deparcment,or&om the Town's website at www va�o����d�.Health Department
Downloadable Forms,
FROZEN DESSERTS:
Fmzen desserts must be tested by a State certified lab prior to opening and monthl�=ther�}�._«i��P�e���
submitted t.p the Health Depariment FaiIure to do so �vill result in the suspeas�oa or revoeaton of�-our Frozen
Dessert Permrt until the above terms have been met
OUTSIDE CAF'ES:
Outside cafes(i.e.,outdoor seaxing with wazter/waitre�s��},must have prior approval from the Boazd of HealYh.
OI7TDOOR COOKING: _-_ _ _ - --- - _----
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`� t� The Commonweaith ofMacsachusdtr
Department oflndustrial Accrdenfs
� O,p`ice oflnvestigatiorrs
� I Cangress Sireet, Suite Z00
Boston,MA 02I1�2017
www.mass.gov/dia
Workers' Compensaiion Insarance Affidavit: General Bnsinesses
Anplicant Information �'lease Print T�eeiblv
Business/Ora T�17ationName: ��SS IIa�E�- fl�ui-r C��u�3 Kc .
Address: '�' �X / �y � - Yv �-rlf-�N�tLa�n �Uit�
—� oY6 1�-� a/� ✓ S�:,�y ed�_395�-7�� �
CitylStatelZip: ��1+ +�N Phone#: T/�-�.t-s • Sa �- 39 �- a ,�L a
Ar�e y an employer7 Check the ppropriate boz: Bosiness Type(reqnired):
1.L�1 1 am a employer with�_employees(full and/, - 5. ❑Retail
or pare time).s 6. ❑RestauranUBar/Eating FstablishmenR
2,❑ I am a sole proprietor or partnerslup and have no 7_ � Office and/or Sales(incl.real estate;auto,ete.)
employecs worlana for me in any capacity. g. �on-profit
�0 WO$CCiS' CAYIlP.incn*�nCC�iC[(LtiICCI] � .
3.�( We are a corporation�d its offxcers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4� and we have 10.0 Mauufactiu�mg
�o employees. [No workers' comp.insurance required]•
11.0 Health Care
4.j] We are a non-profit organi7ation,sffiffed by volunteers,
with no employees_ [No workers' comp.inmm+n�teq.] 12.0 Other
•Any applic�t thet chetk4 box#1 mus[aigo fill out the�sectiw below shuwing tfieirworkers'compcnsation policy mfo�atioa.
ss�����offiars Lave e�empted themselv�s,but the carpotation Las ottxr�emPloyces.a wo�cers'compensation policy is req�rired mmd sach an
�i7atioa should checkbmc nl. �
I arn ar�emplvyer that is pro�v/id�ing��wor�ke�r_s'co ensation iesurance or my employees. Be/[ow� is the poticy informntion
Insurance Company Name:�5"-8' �E� �NJ u/�.9-/�e� �-A m F'A�k-�1�_
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Insurer's Address: '� y S/ G ���D+�1� Dr/ ✓•C
City/SffitelZip:
/�.� lTk✓�EA( O�— - O ��l - �/ o
P-olioy�o�S��t.ia: /-b- — �- � 3 �� ' ' • � �
Attach a rnpy of the workers' co pensation policy declaration page(showing the policy nnmber and eap tion date).
Failise to secure covera�e as required under Sectioa 25A of MGL a i�2 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or on�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 ab•ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance covemge verification.
I do hereby nder the pains penalfies of perjury tltat the informallon provided ab e is irue and corret�
Si ature: � '
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one#• o �- 3 �- 0 6 — Cl u-�S b d= �- �Z' /
Ojjl�c' only. Do not write iathis area,to be completed by city or fown offuial •
Citp or Town: Perm[t/Li�ense#
lssniung Aathoriiy(circle one):
1.Board of Health 2.Bailding Ilepartrnent 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contac`.Pxrson• Phone r