Loading...
HomeMy WebLinkAboutApplication and WCf � �:,�5-�, � d TOWN OF YARMOUTH BOARD OF HEALTH ! i ' ��� APPLICATION FOR LICENSE/PERMIT-201� � ! � , ��oYs� ZU15 � * Please com lete form and attach all necess docutnents ce P az'3' � Failure to do so will result in the return of your�pplication pae et. ; .. . ;,-,. � . : _, .. ; ESTABLISHMENT NAME: / �/NS t * S(�- S TAX ID: LOCATION ADDRESS: g0�- �,r�. S M9 TEL.#: $-3�1 U-7k 10 MAILING ADDRESS: �Orl- � S�' ti/e�t �+''► ��GY E-MAIL ADDRESS: OWNERNAME: �A�.LCL .uA�/ CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: L�z{C.- l� v*�� TEL.#: 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. L - 2. _ Pool operators must list a minimum of two employees currently certified in standazd First Aid and Community Cardioptilmonary 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 fle at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments 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 Establishments, 105 CMR 590.000. Please at[ach 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. N`� /�/�t�l�o� 2. GN� �G���G PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. l��/rlsL /J` ��f,t.Bd 2. �/�'3/'9 �i�l�i�fi��� I� 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. l' oN. �,L L/lrvG��o 2 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-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. /v/�l �tGl�ftiCL�� 2. /��v�� /�e*-���e�a 3. `'TdivT� �G R-'cK 4. RESTAURANT SEATING: TOTAL# --� --LGDGIhG:___.. . . _------- -� ----- OFFICE USE ONLY__- ---__ ------ - __ - ----.- -- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 � MOTEL $t IO INN $55 CAMP $55 SWIMMING POOL$ll0ea. _LODGE $55 =TRAILERPARK $105 WHIRLPOOL $IIOea FOOD SERVICE: � LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# . �0-t00 SEATS $125 �/�666 CONTINENTAL $35 NON-PROFTT $30 � _>100 SEATS $200 I COMMON VIC. $60 �d�5 —WHOLESALE $80 '���.. —RESID.KITCHEN $80 ' RETAIL SERVICE: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE �PERMIT# _<50 sq ft. $50 � >25,000 sq.ft. $285 � VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $I 10 '' NAME CHANGE: $IS AMOUNT DUE _ $ � Q,S.bo : *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'"*** i �3 � � 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 Warker'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: I YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS �i TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be I 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 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 Deparhnent 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 in the pool azea 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 I thereafter. li POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of �I closing. I —_ _ FOOD SERVICE I SEASONAL FOOD SERVICE OPENING: I All food service establishments must be inspected by the Health Department prior to opening. Please contact the i Health Department to schedule the inspection three (3) days prior to opening. �I CATERING POLICY: �I Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the ', reqwred 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.yarmouth.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 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 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 RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. 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: �� ��/ S'� SIGNATURE: ��� i� � i,,� PRINT NAME & TITLE: .L�o .�� l7,C7,Q��j� Rev. 10/01/IS � . ., � TheCommonwealthofMassachusetts Depar[ment of Industrial Accidents Offace of Investigations ' I Congress Streef, Suite I00 Boston,MA 02114-20U _ www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print LeEiblv Business/OrganizationName: �+PVI'�5 �'�t S�✓'>•'� Address: 9'�� � 3� City/State/Zip:� 1A�� /� 0�6`/ Phone #: Are you an employer? Check the appropriate bo%: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail - - - - ' * 6.. [��tawantBar/Eatin�Establishment , 2. I am a sole proprietor or partnership and have no 7, � Office and/or Sales (incl. real estate, auto, etc.) I employees working for me in any capacity. [No workers' comp. insurance required] $• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemphon per c. 152, §1(4),and we have 10.0 Manufacturing ', no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We aze a non-profit organizauon,staffed by volunteers, II with no employees. [No workers' comp. inc„rance req.] 12.❑ Other *Any applicant tha[checks box#1 must also fill out the section below showing their workers'compeasation policy infoxmation. '�. ••If the cocpomte officeis have exempted themselves,but the corporation has other employees,a workets'compensation policy is tequired md such an �,,, organization should check box#I. � � ����.. I am an empfoyer that is providing workers'compensation insurance for my employees. Below is the policy informatioe. ', 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 eapiration date). Failure to secure coverage as required under Seciion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a _-�'�ne-aF�e�l,S09:99 andfer ' ' . ' ' alties in�ie farm ofa s3'0�9JO�flRD�R an��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 Inves6gations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury thai ihe information provided above is true and correct Signature• ��./�Y������� Date: �� / ��� Phone#: O�cial use on[y. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# 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 ��.�.