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Home My WebLink AboutApplication and WC ��u�N :. � � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/P s,; ��!��; (��;r- 1 � �� ''"" * Please complete form and attach all necessa �crc � t� y� ee r 1 S 201 S. ' ��ailure to do so will result in the return�'yo�ap�lir� `.�k t. f�:�=fi�-TF�� .��PT. ESTABLISHMENT NAME:_,,,f�,�t�� TN 1�( TAX ID: LOCATION ADDRESS: � � I�V� TEL.#: 2 �� MAILING ADDRESS: nt 41..�`�( �.� 'T��I�b �L'CC7YY�1�'� E-MAIL ADDRESS: �• �F- OWNER NAME: d CORPORATION NAME (IF PPLICABLE): MANAGER'S NAME: TEL.#:Sb�-��3(j- (�LS 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. ----- }---�d-��-_- ---------_ __ __ ' _- Pool operators must list a minimum of two employees currently certified in 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. 1(�C) 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. 1. �l � 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1_.�� 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. � ( � 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. ��1� 2. 3.—� 4. RESTAURANT SEATING: TOTAL# _------ _--- _ --_ _—. _ -- ._ ---��£�-�-�P?�� ---- ---- - ---- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I�&B $55 CABIN $55 MOTEL $110 'INN $55 CAMP $55 SWIMMING POOL$110ea. �LODGE $55 �J _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# L�TF'ENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ,�,�UNTINENTAL $3�(,'�0 C.6/VGEYL NON-PROFiT $30 _>100 SEATS $200 _�OMMON VIC. $60 p� (;� =WHOLESALE $80 —RES[D.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERM[T# 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 $110 NAME CHANGE: $15 AMOUNT DUE _ $ S5. OO *****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 customaxily 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 I POOL OPENING:All swimming,wading and whirlpools w�ich 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 standaxd 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.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: �I Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR.COOKING: Outdoor cooking;preparation,or display of any food product by a retail or food service establishxnent 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: l�`��l� SIGNATURE: � PR1NT NAME & TITLE: ..� �� 6 w-��i J'� d�/��t`� Rev. 10/01/15 e ; � , �� The Commonwealth ofMassachusetts Department of Industrial Accidents iOffice of Investigations ` 1 Congress Street, Suite 100 Boston,MA 02114-2017. ; www.mass.gov/dia ; Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information ��--(�f��r �,nt �'v Please Print Le�iblv Business/Organization Name: ��`1��d'u �-� Address: � City/State/Zip: - cc,�v►�, Phone#: S('j�2�j P�op'ZS � Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail r part-time).* 6. ❑ RestaurantlBar/Eating Esta.blishment - 2. I am a so e propnetor or partners ip anThave no _ __ - - - ---- ------ - - 7. ❑ Office and/or Sales (incl.real esta.te,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Enterta.inment 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 are a non-profit organization, staffed by volunteers, � with no employees. [No workers' comp. insurance req.] 12.�.Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the poldcy information. 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-yearimpnsonment,as we1l as civiI pe�s in t�e iorm o a f�re---- of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here certify,under the pains and alties ofperjury that the information provided above is true and correct. � Si ature: 'i��v� Date: G`'� �l � Phone#: � ��'��— �v DoZ.r . Official use only. Do not write in this area,to be completed by city or town officiaL ! City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Of�ce 6.Other Contact Person• Phone#• www.mass.gov/dia ; I , ACO[7� a►r�twwoarrrn � � CERTIFICATE tJF PR�PERTY INSURANCE 12/2g/2014 TNtS GERTIFICATE IS ISSUED AS A NUITTER pF INFORMATION ONLY AND CONFERS NO RIOHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIYELY OR NEGATIVELY AN�ND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETVYEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CERTIRCATE HOLDER. If this certificate is being prepared for a party who has an MsuraMe frrterest in the property.do not use th�form. Use ACORD Z7 or AC�2D 28. �D�� p�,�; 1Cathy 3ilvia Tha Fair Insuranca Aqsncy Iac. �+E . (508)775-3131 F� �,csoe��9o-ie�� 619 Main Straet � .�� ais 3uifia 7 � a�n�.� Centerville MA 02632 � 00002468 iNsut�s n�oRo��c� rwc s INSUf�O U�$U�tA:L�. C�S OP LOl1f10II Nancy Johnson Tnvestment Trust PO Box 342 ��B' ��ur�e c: INSURER D: Hyannis I�► 02601 iNSURER E: F: COYERAGES CERTIFICATE NUAIBER:CP1412500166 REy1.gION NU�ER; i.ocanoN oF v�MisEs i aEacwrnoN oF waov�r��coa��m.�aanonu rs.w.�rs sdnam..n nwn apae.a raq�..d� I -- LCi.`.�__D,SLQ15: 15Z. tawrw s�n��a f _p.,][�ou#h-r---lA1„�..,.11j6'J3.—___ ____ __ _. _�____� � —. , _ _ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAYE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANQING ANY REQUIREMENT,TERM OR CONDITiON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE tSSUEQ OR MAY PERTi41N, THE INSURANCE AFFORDED BY THE POUCIES DESCRtBED HEREIM IS SUB,lECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PQLICIES.UMITS SHOYVW MAY HAVE BEEN REDUGED BY PAID CLAIMS. 'LTR TYPE OF INSURANCE POLICY NIN� �Y�TIVE POI.�Y EXP�RA710N (�! DATE(YWDWYYYYj COVEREDPROPERTY UINTS X �rto�er X eun.wwc s 33 0 CAU3ES OF LOSS OEDUCTIBLES pERSONAL pROPERTy s ; . gp�C BUIL[NNG ; x eusu�ss� s 5ao � BROAd CONTENTS �T��E � s ; A �Ec�- 888;5364 11/5J2014 11/5/2015 �M'��.� s � �rHuua� euw�r�n.nu�c s j WIND BLANI�T PERS PROP s � FLOOD Bl�4NI�T BtAC 8 PP s X �� S {� X �� S , INIANO MARINE TYPE pF ppUCY . $ ' CAUSES OF LOSS S NAh1ED PERH.S POLICY NUM8ER s S CitlIY� S TYPE OF POLICY s , S BOILER 8 MACFNNERY/ EQUIPYENT BRFAImOWti � S s s s sa�cuu.coNanoas r onrat c�w�oEs�nmcn nc�rte�m.a�R.m�a sa,ww.,n more s�.ce�rey�rroa� — CERTlFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCR�ED POLICIES BE CANCELLED BEF'ORE 71iE EXPIRATION DA7'E THEREOF. NOTICE YINLL BE DELIVERED IN Nancy Johnson ACcoRDANCE wmi 7F�PouC1r p�tOVIs10Ns. PO Boa 342 Hyannis, MA 02601 �TM��'�� Kathy Silvia/FAIMCl �� • ��✓�Q�_ 'ORD 24(2'008l09) �199b�-2008 ACORD CORPORA710N. AII righls rsserved '4 t2oosos) The ACORD name and logo are regisbsr�ed rr�rl�of ACORD