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Home My WebLink AboutApplication and WC � �.m...�,.�.. _�_��-.��}��N� f , �� • TOWN OF YARMOUTH BOARD OF HEALTH ' ; 'I � � APPLICATION FOR LICENSE/PERMIT -2�} , ��_;� � � �� ..,. t� * Please complete form and attach all necess��n�s by De ber 1 S 201 S_ � Failure to do so will result in the ret y, pp �'T ' �' '=; u��` c��'a lication c�:=. _s , . � S:.y ,.... ..e�...,..�..e.,.._ ._.._..._�-.�.�..�.J E�TABLISHMENT NAME: l�'� TAX ID: � �- LOCATION ADDRESS: �12� �' �'- � TEL.#: S"a� �� MAILING ADDRESS: �" � s- �'`�' b�6'� ' E-MAIL ADDRESS: `i��i� ��L°a i"� OWNER NAME: �! /Ll� c-dlv CORPORATION NAME (IF APPLICABLE): -'�'��- �� s' � 1VIANAGER'S NAME: '�n, M ,�v�� TEL.#: s"�� S'�Ysj's''° MAILING ADDRESS: -- i ' i PbOL 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. '' � ' - - _ . _ __ ------ - ----� --- --- -- -- - ---- _ - _ _ __ _ 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. L' 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 Establishm�nts, 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. /�v.r! ��-,r�-C��o 2. ✓��t/` /�i�'��-�� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. --� � — 1 � ,,�'o.v,� �/j�'��C�iu��la � 2 i G�'1 /l�ic.�� -- 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. ' �/L�CGu�� 1. /o�1/i /v i 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. ,��'o,..� �� /P/'�'v�j` /U►zl�� 2. 3. "1'c?iv, /U�r�Lwt/lv 4. ' --i�'`sTAURANT SEATING: TOTAL# �"� I -- ___-- _ _ _-- _ - --_ ��-� US�-@�'��__ __ . —_ — __ _______ —____ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 ; II�.N • $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: L CENSE REQUIRED FEE �tIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � � 0-]00 SEATS $125 �bb�o57 CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 1 COMMON VIC. $60 �`E�/ _WHOLESALE $80 —RESID.KITCHEN $80 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 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ � ��'�J.dO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I „ _ . . 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: '/� NO YES 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 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 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 Board of Health. OUTDOOR COOKING: 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 �I EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE SITF,�� DATE: /�� SIGNATURE: ✓' � PRINT NAME& TITLE: `✓+�f”' ��'I� t�Z�/'�'•'ti- Rev..10/O1/15 w 3 � The Commonwealth of Massachusetts _ Department of Industrial Accidents � -- Office of Investigations � I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia. Workers' Compensation Insuravice Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: i�.a'"'� � �lo�'�—. � Address: �1�' �� Z� City/State/Zip: ,J Bv�^ g�� /� �� Phone#: S�� 3�� G�� Are you employer? Check the appropriate boz: Business Type(required): � 1. I am a employer with�_employees(full and/ 5. ❑Retail { or part-t�me).* 6. �'�staurantlBaz/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. [No workers' comp.insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainxnent 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 E 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 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 ! oxganization should check box#1. I am an employer that is providing wo kers'compensation insurance for my employees Below is the pollcy information. Insurance Company Name: 9N�'" ��r'"�� Insurer's Address: �0 6 o f- l�� City/State/Zip: ��- �� ,�2�.� v�-1.� a�� Policy#or Self-ins.Lic.# �� s�� yy37 �ra"a-Expiration Date: l"�� Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure covera e as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a -----_ �=—.z____ fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the�orm o�a-�Of' an�a�ine - � 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 ' under th ' s a d penalties of perjury that the information provided above is true and correc� G=efi's� Si�nature• -�� Date: I!-��`� Phone#: S'o�- 3��- s�'��'�' � 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 Office � 6.Other ' � Contact Person• Phone#• � www.mass.gov/dia I � �� a��q�rrooirvm I A��' CERTIFlCATE QF LIABILITY INSURANCE io�s�2o,s � THIS CERTIFICATE IS ISSUED AS A MATTfR OF INFQRMATION ONIY AND CONFERS Nd W<iHTS UPON THE CERTIFICATE HOLDER.T}IIS CERTIFICATE DOES MOT �0.FFIRMATtVELY QR i�GATIVELY AMEND, EJCIENO QR ALTER THE GOYERAOH AFFQRDEO BY THE POLICIES BELOW. THIS CERTIFICATE QF INSURANCE DOES MOT CONSTITUTE A CONTRACT BETNIEEN TIiE tSSWNG INSURER(S� AUTHORIZED REPRESENTATIVE OR PRODUGER,AND THE CERTIFlCATE HOLQER IMPORTANT: If d�e ceRNicabe hoider b sn ADDITIONAL INSURED.ths polky(ks)must ba endorsed. M SUBRdQAT�N IS WAIVED.aubjoet to ttw tertns and conditia�s of ti�poNcy.cartain poNcios may require an andorsement A sta�emeM on this certlRcate does not eo�Mer rights to tl�e certlflcate Aoldsr in lieu of such endortwnetN(s}. PRQOUCER � A USI INSURANCE SERVICES LLC 5700 POST RD nHpNe �877�46g..272g F� ,866-g2g-2424 PO BOX 1158 -r� . Certificate cQhanover.com EAST GREENWICH,RI 02818 ��ci c� wuC t ��A: it�zens ns o o ca 31534 x�� s; Hanover Insurance Co 22292 TNT FAMILY ENTERPRISES �R�. DBA ROUTE 28 DINER W�R 0: 928 ROUTE 28 H�tlRER E: SOUTH YARMOUTH MA 02664 ��F; COYERAGES CERTIFIGATE t�7M8ER: REMSION NUI�ER: THIS tS TO CERTiFlf THAT THE POUCIES Of INSURANGE LISTED BELOW HAVE BEEN lSSUE�TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD 1NpFCATEO. NOTVWTH3TANDING ANY REQUfREMENT,TERM OR CQNDITI�N OF ANY CONTRACT OR OTMER DOGUI�IENT WITH RESPECT T8 WHICH THiS CERTIFiCATE RIAY BE iSSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE 'fERitS. EXCLUSIONS AND CONDITIONS OF St1CH POLICIE3.LiMITS SHONM MAY HAYE BEEN REOUCED BY PAIO CIAiMS. 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