HomeMy WebLinkAboutApplication and WC ' TOWN OF YARMOUTH BOARD OF HEALTH C3L3GC��OdL�D 38
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� � APPLICATION FOR LICENSE/PE �„ IT>-20- � � J Nv ,L ] 2O�5
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* P l e a s e c o m l e t e f o r m a n d a t t a c h a l l n e c e s s a r y d o_` : �y�e e e m b ;'1 S��0 1 5.
' Fail�e to do so will result in the return of y�„ur ap�lication pack �. H�qLTH DEPT.
E�TABLISHMENT NAME:�?e�c�.-wo,., *�Z`�3 c� TAX ID• �\-\
LOCATIONADDRESS: '-��� MA�� S��e�� �es� `0.rrnoJ�� �MA TEL.#: So$ -�-TS-i2(o3
MAILINGADDRESS:�-�ce�ns�v,q Ot�. -Qo gox �5�o S?�c�i� , �h:� �-4SSc�t
E-MAILADDRESS: rv��\•,os;er CR? S�tec�wa,a . c--ow�
OWNERNAME: c�eec�wo.v �LC
C(�RPORATION NAME (IF APPLICABLE):
1VIANAGER'S NAME: ��on; c� � a o.�- �4�.�z c�.r. ec TEL.#: �08- "�-IZ�3
MAILINGADDRESS:�I�I Mc.;r S�c-c �� irJes� `So.rw�o� ��M�A o2co-13-�1$4�}
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.
1. 2.
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
ernployees below and attach copies of their certifications to this form. The Health Department will not use past
y�ars' records. You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PR�T�CTI�N 1VIAN�GE��--CE���'ICAT�ONS: _ _ _ _ _
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. �n�t�h�y L'� 1"`�l 0.v�o�t o� 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. ��.�o��.,��. N1:\ �,�o., � 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.' ��.��,�.;,, � M;���o., �. 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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 _CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 WHIRLPOOL $I l0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30
_>100 SEATS $200 _COMMON VIC. $60 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 .�Z _FROZEN DESSERT $40 �TOBACCO $110 ��
NAME CHANGE: $is AMOUNT DUE _ $ 2,(00.00 '
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION '
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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 !
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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 �
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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 i
closing. i
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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 i
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.ua 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,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: �1��� � _SIGNATURE: � L.�C�-��
- PRINT NAME&TITLE:�orc�\� �.. E��:s�o t� �c eas�.r�� i Spc��.�,�
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Rev. 10/O1/15
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
� � Office of Investigations
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� ' 1 Congress Street, Suite I00
Boston,MA 42114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Legiblv
Business/Organization Name: ��e��w c�,� ��C ��1�`a, ���e��a a,���'-�3 S
Address: '�-Ey\ �Q•� S�Ee e�
City/State/Zip:W eS� �c�.r�.�.o��� �MPr oz�13 Phone#: '�08 - �� 5 - lZ� '�3
Are you an employer?Check the appropriate boz: Bus'i❑ness Type(required):
1.0 I am a employer with �� employees(full and/ 5. Retail
or part-time).* 6. ❑ RestaurantBar/Eating Esta.blishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(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. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.Q Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.X❑ Other �-L c-
*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'compensarion policy is required and such an '
_ __ • • . cheek ba��.--- __ -___ . - ---- ._ '
I am an employer that is providing workers'compensation insurance for my employees. Be[ow is the policy information. '
Insurance Company Name: P�e as� s@� c���-4���a, ',
Insurer's Address:
City/State/Zip: '
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaratian page(showing the policy number and egpirafion 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-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perjury thrrl the information provided above is true and correct.
Sig.nature: �.� Date• /���/�J�
,
Phone#: �3�1 - 8(R "3 - `l 3$ 2
Official use on[y. 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#: '
wwwmass.gov/dia
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A��� CERTlFiCATE OF LtABILITY INSURANCE oareE��oamrv�
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THIS CERTlFICATE IS ISSUEp AS A MATTER OF lNFORMATION ONLY AND CQNFERS NO RIGHTS UPON THE CERTIFIGATE WQLpER. THIS
CEitTIFlCATE DQES NOT A�FIRMA7IVELY RR NECsATIVELY AMEN�, EXTENO OR ALTER THE CaVERAGE AFFQROEO BY THE PpUC1ES
BEL4W. 7H4S CERTt�ICA?E OF INSURANCE DOES NOT CflNST1TUTE A CONTRACT BETWEEN THE lSSUING tNSURER(S), AUTHORiZED
� REPRESENTATIYE OR PRODUCER,AND T}tE CERTIFiCAFE HOLdER.
� FMPOR7'ANT: !f the eertifEtate hotder"u an ADDITiONAL 1AiSUREO,the poticy(ies)must be endorsad. If SUBROGATION 15 441AtVE0,subject to
the terms and conditiuns of the policy,certaln poticies may roquire an ersdarsement. A statement on thts certificate does not confer righYs to t#se
certfficate hoider in Ifeu af such endorsemea s.
': PROOUCER �
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; Hyfant Grpup-Cleveland PNONE �FA%
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j� Inde endsnce OH 44131 $DORE
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� COVERAGES CER7I�ICAtE NUMBER:378100648 REVIStON NUMBER:
i THIS IS TO CERTIf'Y THAT THE POLiCIGS OF tNSURfWCE 1.15TEp BEIOW HAVE L3EEN ISSUED TO TfiE INSURED NAM�p ABOVE FOR TME POLICY P RIOO
1NDICATFO. [JOTWITHSTAN4iNG ANY REQUIf2ERAEN7,TERM QR CONDITION OF ANY CONTRRCT OR OTNER �OCUMEKT Y+AT'H RESPECT i0 WNICH TFlIS
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