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Home My WebLink AboutApplication and WC� E , ' � E � � ► TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERMI'T- 6� P; �; �� 9 20�5 `'"" * Please com lete form and attach all necessary docum��p3'�. .... 1S' : IS. ' Failure to do so will result in the return o�.y,our�pp}�ata� ' " t. DEPT. ESTABLISHMENT NAME: � /-tS�D TAX ID: LOCATION ADDRESS: � TEL.#: � 1 MAILING ADDRESS: S D 6 E-MAIL ADDRESS: L n ' � � ` � � OWNER NAME: CORPORATION NAME (IF APPLICABL ): MANAGER'S NAME: , TEL.#• �3 t� 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. 1. � 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 a11 times. Please list the ernployees 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• FbOD 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. 2. � PERSON 1N CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ; 1. � � 2. � A�,LERGEN 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 Aealth 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# � ! � _ __--_ _--- __ _ ____ __—�FFICF USF (2]YI��___.__ - -- _ — ._ _ . — -- _ _' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $Il0 INN $55 CAMP $55 SWIMMING POOL$I l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �OBS _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSB 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 ��'j _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ /(05.QQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � ��,. j � � 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 VVorker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR _ I WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHEDV Town of Yarmouth taxes and liens must be paid prior 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 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 thirly(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 sehedule 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. -�-_-�_.-� — - _q _ ____ . ___—�ZSIj��R'�ICE _ _: _ .,_ __ __. 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 RETLTRN 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 COMMENCEMEI�FT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: Rev. 10/O1/15 ` � � The Commonwealth ofMassachusetts _ _ _ Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite I00 Boston,MA 02114-2017 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: -� Address: CJ� ��9 P � —r,—t—.o., , '. City/State/Zip: Phone#: ��j D �� ;' Ar�e yo an employer?Check the appropriate boz: Business Type(required): ; 1.L,� I am a employer with i� employees(full and/ 5• ❑ Retail ' or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment _ _ _ - - -- - - —__ _ _ _ _ - _ - __ _ 2. I am a sole ro rietor or artnershi and have no P p p p 7. ❑ Office and/arSales(incl.real estate,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 corporadon has other employees,a workers'compensation policy is required and such an � organization should check box#i. I am an employer that is providin workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: ,_��) Q�� Insurer's Address: f� � City/State/Zip: � �� Policy#or Self-ins.Lic. # 1 �C�,�- a.c��l (�x 33-3-�y __ __ Expiration Date: `�— �— �� I Attach a copy of the workers' compensafi n policy declaration page(showing the policy number and egpiration date). 1 Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties af a � fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOY VJORK ORDER and.a tine of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certi under t ' and nalties of perjury that the information provided above is true and correct. � Si ature: Date: � � � Phone# � � Official use only. Do not write in this area,to be completed by city or town offaciaL 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 �'�l1��.�E�'�` u�E ro�t � WQRKERS COMPENS�►TION �, cr sc,� AND EMPLQYERS �IABI�ITY POIICY TYPE V tNFORMATION PAGE WC 00 00 Of ( A} POLICY NUMBER: (IEUB-2676X33-3-14) REf�WAL OF (IEUB-2676X33-3-13) INSURER: TFE TRAVELERS II�ENUVITY COMPANY QF COPG�CTICUT �. Ncc� eo co�E: ,2�� INSURED: PRODUCER: JAI�S hNR�EY HART INS AC�NCY ING DBA PUTTERS PQRADISE P 0 BOX 70Q P� �x � BUZZARDS BAY MA 02532 HYAANISPORT MA 02647 It1SUred iS AN INDIVIDUAL Other work plac�s and iderttification numbers are shown in the scheduie(s) attached. 2• T�paicy pefiod fs from 01-01 -i 4 to 01-01-15 12:01 A.M. at the insured's mailing add�ess. 3. A. WQRKERS COMPENSATION tNSURANCE: Part One of the pdicy appiies to the Workers Compensatron Law of the state(s) listed here: .� t�lA s �� o� � B. �MPLQYEi3S LIABlLITY lNSURANCE: Part Two of the policy appiies to work in each state I�ed in �em 3.A. Tt�ifmits af our(iab�ity under Part Two are: � Bod�y Injury by Accident: $ 50040o Each Accident � Bod�y Injury by Dis�se; � 500000 Pdicy Limit a� Bod�y injury by Disease: � 500000 Each Empioy� � �.,� C. OTHER STATES iNSURANCE: Part Three of the pdicy appli�to the states, if any, listed here: �`� AL AR AZ CA GO GT DC DE FL 6A HI IA ID IL IN KS KY LA ND NE MI h�V p� Mq MS M�7� WC PE Ni NJ NM NY NY �C OR PA RI SC SD TN TX UT VA VT WI , a� y�yr = a�� D. This policy indt�es these endorsemerrts and schedules: A� SEE LISTING OF ENDORSEh�NTS - EXTENSION OF INFO PAGE o..."'�� s 4. Tt�premium for this pdicy w�l be determined by our Manuals of Rules, qassifications, Rates and Rating _ Plan,s. Al) required information is subject to veriflcation and change by audit to be made Af�1uALLY. .�. .� � -a�,,,k_ �t •e.� QAT'E OF ISSU�'-�`t-'�'i'=13 SS OFFtGE: FAJDSQN/BflSTON 126 DIRECT BIL� I' PROD#�CER: HART INS AGENCY INC XJ289 i ( 00696� i � 1