HomeMy WebLinkAboutApplication and WC a TOWN OF YA OUTH BOARD OF II�ALTH ���'�`��'n�� I
� � APPLICATION FOR LICE { � 1'�'k, $�P 2 2 ZU15 ,
�"' Please com lete form and attach a11 n� s oc�" ember 2014T I
*
Failure to do so will result in th ' u�app ica�ho
ESTABLISHMENTNAME: r;rn�ver ; vr T ID: " I
LOCATION ADDRESS: P� r h o �Ja TEL.#: � 3U' O ('J
MAILING ADDRESS: r o� 0 0
E-MAILADDRESS: C.h2 a Me � COr'1
OWNER NAME: -��
CORPORATION NAME (IF APPLICABLE): Yrt V e5 3��an
MANAGER'S NAME: � I'd,n R 2 e r TEL.#: �3 8"2 S a6
MAILING ADDRESS: a 2f wuM Por
POOL CERTIFICATIONS:
The pool supervisor must be certiTied 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. i
1. 2• I
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.
�. �.,�a G���, Z. C�d�� C�., w�� ,
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours oF operation. I
1. / l J. �71,cc � _ 2. ��� e� r��Ti�
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification, �i
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certifica6on 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. F��t �, Gc�11,� 2. �o�T�on �� a� i
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 i
attach copies of employee certifications to this form. The Health Department will not use past years' records. I
You must provide new copies and maintain a file at your place of business. I
i. D�a� Q� garker 4: /'1arko 13 �zo�►c�
3. /
RESTAURANT SEATING: TOTAL# � b
OFFICE USE ONLY '
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICMOTELEQUIRED $E 0 PERMIT
B&B $55 —CqgM $55 —SWIMMINGPOOL$110ea
—��r $55 _�pgpILERPtIRK $$OS _WHIRLPOOL $il0ea
LODGE $55 ..
FOOD SERVICE:
� CENSE REQUIRED FEE ���I�T�,#, LICCONTINENTALD $35 PE�IT# LICNON-P O�FIT�D $30 PERMIT#
�0-100 SEATS $1z5 �'��'.kt.� COMMON V[C. $60 �� WHOLESALE $80 .
I >100 SEATS $200 �- —RESID.KITCHEN $80
'�` RETAIL SERVICE:
,I LICEN�S6 REQUIRED $50 PERMIT N LICE 5 00 sq�RI�D $2 5 PERMIT# � LICVE��QUF OD $25 PERMIT N
q =FROZENDESSERT $40 _TOBACCO $i10
� =<25,000 sq.ft. $150
AMOUNT DUE _ $
j NAME CHANGE: $15
� PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'**
**!Yk
i
I ADMINISTRATION
Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal
i of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
CompensaUon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
I AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
iCERT. OF INSURANCE ATTACHED
� OR . /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 'v
� Town of Yannouth taxes and liens must be paid priar to renewal ar issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitarions ofMotel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinazily 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 thirry(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, sha11 generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
De artment rior to o enin . Contact the Health Department to schedule the inspection three (3)
he Health g . .
b t P P
Y P
days prior to opening. PLEASE NOTE: People are NOT allowed to srt m 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 three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yannouth 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.varmouthma.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 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 COOHING:
Outdoor 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
i THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014.
i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
i EQUIPMENT,ETC.), M[JST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY%Q%(�A SITE PLAN.
y
DATE: d�_Z2 _�S SIGNATURE: ; ��� _
PRINT NAME& TITLE:��, C��tj. C �`
—��--
IRev. Ii/03/I4 ..
�—�,
� The Commonwealth ofMassachusetts i
Department of Industrial Accidents i
O�ce oflnvestigations
� I Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: General Businesses �I
Anulicant Information Please Print Legiblv
Business/Organization Name: ��e� � � 1�u f�c n'f" Cj co t,� �� p Q� �r„�n a Ve ra f,.�s+���^�e- �i
Address: � � f�U��tc v�
City/State/Zip: `��"»u�� �or� 11� oa6�s Phone#: ��-I � 3 3� ^ Q � ��
Ar,��e °u an employer?Check the appropriate box: Business Type(required): �'',
l.LuJ I am a em lo er with � � 5. ❑Retai]
p y employees(full and/ I
or part-time)."` 6. �RestaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity. g, �Non-profit
[No workers' comp.insurance required]
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertaimnent �
their right of exemption per a 152, §1(4), and we have �0.0 Manufacturing I
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
4.❑ We are a non-profit organizarion, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other i
*Any applicant thaz checks box#1 must also fill out the section below showing their workecs'compensation policy information. i
**If The coipomte officers have exempted themselves,but the corporation has other employees,a workecs'compeusation policy is required aad such an
organizabon should checkbox#1. I
I am an emp[oyer thai is provipding workers'compensation insuranc for my employees. Be[ow is the po[icy information. ,
Insurance Company Name: f a�X �✓�5 i.i��n C� �'�C���In C '
Insurer's Address: I 5 O Sa��a s s �r;N � I
DI_,, /,' �/ ;
City/State/Zip: {�-OG�"'�-5��� I�1 ! �N��U
�
Policy#or Self-ins.Lic.# `� 6W�G�g 13 0►J Expiration Date: �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under SecUon 25A of MGL a 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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce d the pains and pena[ties of perjury that the informaiion provided above is true and correcG
S=g�ature�/�"���0 ` Date• C7 _l - 7� �S
Phone#:
Officdal use only. Do not write in this area,to be comp[ded by city or town o�ciaL
City or Town: Permit/License#
Issuing Authority(cirde one):
1.Board of Health 2. Building Department 3.CityPfown Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
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