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Home My WebLink AboutApplications and WC MQ � � �* TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENS�/PE�2MI - ,``-, .�DE(; ; � �OfS : ,, `'°' * Please complete form and attach a11 necessar�do� �� e �� zber 1S 2015. � Failure to do so will result in the retu�i of�iu�=�p��a°�on p ke . DEPT. ESTABLISHMENT NAME: Cc�c,, C�ree✓�o ua I� TAX ID• ; LOCATION ADDRESS: dd'7 ��✓►e Sfi �r��wrau�'G► �or� HtA c�1�'7.� TEL.#: .57�5-�(��-�3�� MAILING ADDRESS: �1�17 b+1�1(0«�S f y�.��v�ov� �oo�� o��`�� E-MAIL ADDRESS: r►n > Z.o�,�,v� C�9 5 cvv�,� �o� OWNERNAME: ' � s u�u�c� o r� ' CORPORATION NAM (IF APPLICABLE): ��e a5 �oa v-e MANAGER'S NAME: M�� i le TEL.#: S`� - -L1 � MAILING ADDRESS:�,�L/ '7 �i llo�,v �f' ��armov� !�, l�'l�f ��?� � 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. �J'I' - 2• i i 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. � i L 2. I 3. 4. i i 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. /`T v�'t y G.o� 'v� 2. � PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. v Z aJ�n 2. i 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. ; i � 1.�, v Za�,r, 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. 2. j 3. 4. � RESTAURANT SEATING: TOTAL# � _:_4F'EIC:'E_SI�Q_lYL�.__ _ _-----___ � -------- ____._ ---___--_—_ -- LODGING: _ _ . __ __ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# , B&B $55 CABIN $55 MOTEL $110 ' _INN $55 TCAMP $55 ��IO� SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $t05 _WHIRLPOOL $110ea. FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# � 0-]00 SEATS $125 _CONTINENTAL $35 � NON-PROFIT $30 �� f _>100 SEATS $200 _COMMON VIC. $60 _WHOLESALE $80 I —RESID.KITCHEN $80 C 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: $is AMOUNT DUE _ $ 8S•OO �^* �--��-� � *****PLEASE TURN OVE$��i��MPLI��'��t$SIDE OF FORM***** E f 0 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 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 EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:^ I a�i0 I f� SIGNATURE: + PR1NT NAME &TITLE��S`�'ti � �lCec�"C�r Rev. 10/O1/15 i _ � ; � ` TO WN OF YARMOUTH Boazdof � � Health = 1146 ROIJTE 28, SOUTH YARMOIJTH,MASSACHUSETTS 02664-24451 - �" Telephone(508)398-2231,ext. 1241 Health Fax(508)760-3472 Division APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN (IJse back of application if additional space is necessary) -FE�:-�55:98' Name of Camp:��;�,� �('P p � ,� ' Site Address: c�c�� i✓1 P, �7f" 7�l�,`rn o� ��}� �oZ� �� Site Address: Tax ID Number(FEIN or SSl�: E-mail��v,Z.c�1nn��5cd�rinq mp1'Cc U �� Type of Camp: Day(less than 24 hrs.) '� Residential(24 hrs.) Hours of Operation: M� /' g(�„yry� "��-�✓l Dates of Operation: Opening:__��v'�/ �, a D�jo Closing: q US� � o�O f� Name of Camp Owner: �' � S � c� .�.te�'Icck i Office Address: � � s i Office Telephone Number: �j�'�� " .��a~�,��o� Name of Cau�p Operator(if different): Address: Telephone Number: Camp Director: m\l 2Q,�/1� - a�a��s: d�`� l�}11E o w �� r�.rm o�r. �a►"�� ,� �.�� Age: �.�.r'y �J� Telephone Number: ,5��"��.. _,�� Coursework in Camping Administration: � , Previous Camp Administration experience: `7' V a S G?S (' ,n� �P r_- !� i --�7e ��----��r � Health Care Consultant:_ scso . �� . . � �� l ea- M D ; Type of Medical License:� ed/'G 1 MA License number: c� Oc,�,,5 g�j ' Pleu san� C-a,ke Me o�c�c o f f,ce 3 Address:�_�S3 P/eaaa,�� i-a,�.<e �Ve; ��.fw�c�,�.� Telephone: �Q�-L/, a'jd ,S , i � 0�0�15 1 of 3 � � � I Hospital for Emergency Services:�Ps� 5D1�` Health Supervisor• �.� r,��, Age: L/ 9 Type of Medical License,Registration or Training: � ,1� � E�Q� Swimming Area: Yes ''� No a�ice O cc,��v�� If Yes: Fresh Water � Ocean Pool CPO Specific Onsite Locations: 1\n,� �n �f I prX� f ' Water Quality Testing Performed By: ��'�(1S�D�� v� � C7CCi (--� Aquatics Director: Name: (� t/t� K .�/'V Age: �_ �� — Lifeguard Certificate issued by:�1/SLovTS Ot �INle(')CL� Exp. Date: �rr Il'p American Red Cross CPR Certificate:��/S C � ��r"�1�-1 � Exp. Date: Cp 1� American First Aid Certificate: NS C � %33 f]/a Exp.Date: �y �� ' Previousaquaticssupervisoryexperience: �'Q,lt�'lGS �1`eL�Oc 4Su�eC�/��ye�"S ; ,i Watercraft/Boating Activities: Yes '✓ No Describe: I � Compliant with Christian's Law: Yes � No � Food Service: Is food handles, served or prepared? Yes No V � ! To what extent? Snacks Cooked and Served by Staff ; � If cooked onsite Food Mana er submit co of ServSafe � � g � PY ) �V Z.G��rl - S�.(V Sr��P � Catered if so,by whom? _ _ _ � � i Is refrigeration available for perishable foods? Yes '� No ; C a.�rn�c�5 1or�►�� En�� o�✓� ! u r�can ' Fire Arms Instructor: ' Name: YV J ��[�'�� )�,OrJ1 r0�- � Narional Rifle Assn. Instructor's Card(or equivalent) � Date certified: �U J�ei �� D�a- Expiration Date: �C 3 �� U�(o ! � � � I i � 0��30��5 2 of 3 I f � i r Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SOI�I of each staff person and volunteer who may have contact with a camper? Yes '�� No IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1) WEEK PRIOR TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION ' WITH THE BUILDING AND FIRE DEPARTMENTS. By signing this application, I acknowledge that I have submitted all required documentation and I am in compliance with the State's minimu_m_ _standards for Recreationr�l__C�%_mps for Children,State Sanitary Code Chapter lY, 105 CMR 430.000. SIGNED: � ..-- PRINTED: Y� Gl, ✓� DATED: 1��J� /� See the nezt page attached for a list of documents that must be completed and submitted ; before your application can be fully processed. You are strongly encouraged to complete ; these documents as soon as possible and submit them in advance. This will expedite the process. ' i � i � i � F � i � � � � i � � j i � oa�sons 3 of 3 ' I i 1 � � � � Reauired Documents ' See the MA Regulations for Minimum Standards for Recreational Camps for Children, State Sanitary Code, Chapter IV-105 CMR 430.000 and the guidance documents issued by the Department of Public Health, Division of Community Sanitation for additional assistance with developing the following documents. Check Documents Submitted ' *Staff information forxns(see attached).................................................................. i�'' *Procedures for the background review of staff and volunteers(105 CMR 430.090)............. y *Copyofpromotional literature(105 CMR430.190(C))............................................. . b�6 �,f Y ��,-�d�Cp�Q *Procedures for reporting suspected child abuse or neglect(105 CMR 430.093).................. �/ *Health care policy(105 CNIR 430.159(B�),including immunization records......... ............__ __ _ __ _ _ _ *Discipline policy(105 CMR 430.191).................................................................. 1/ *Fire evacuation plan—approved by local fire department(105 CMR 430.210(A)).............. ✓ *Disaster plan(105 CMR 430.210�)).................................................................. �/ *Lost camper plan(105 CMR 430.210(C))...........................................................:. � *Lost swimmer plan(105 CMR 430.210(C))........................................................... ; *Traffic control plan(105 CMR 430.210(D)).......................................................... *Day Camps—contingency plan(105 CMR 430.211)................................................. *Primitive, Trip or Travel Camps — Written itinerary, including sources of emergency care � /1 and contingency plans(105 CMR 430.212).............................................................. l� ' *Current certificate of occupancy from local building inspector(105 CMR 430.451)............ f � *Written statement of compliance from the local fire department(105 CMR 430.215)........... ✓ f *Aquatic plan,including Christian Law,PFD fitting tests,water testing and swim tests...... ; I Attach the names, ages, applicable current certifications (if any), such as First Aid, and the anticipated role at the camp of all supervisory sta.ff(see below). Use as many pages as necessary to complete this. Please: If you are applying for an original camp license for a camp based in Yarmouth, you must file a plan showing the following with the board of health at least 90 days f __ _ bef�re your�esire�vpening date f See�VEC�L-Clr. 140 § 32A}: __ _- -------- - - ; ➢ Buildings, structures, facilities and fixtures ' ➢ Proposed source of water supply � ➢ Works for disposal or sewage and waste water � � Supervisory staff ineans those persons with the responsibility, authority and training to ; provide direct supervision to camper groups. This may include counselors, junior ; counselors, general activity leaders or other staff who provide supervision to campers � without assistance. ' � 04/3��5 � , i i • • t � � � t� I�tJTI�E ...� �. � IiTU�I�E TtJ � � � � T'f.� � EMPL�Y�ES ��Y�ra� .. � �.;: �� E�VII�L��E�S �� ,�� The Cam�nonwealt�. of 1V.ias�a�huset�s D�PAI�TMENT OF INDUSTRIAL A�CIDEN�S b00 Washingtun Stireet, �oston, Massachuset�s 02111 � 617-727-4900 As rec�uired by Massaehusetts General Law,Chapter 152,Sectians 21,�22,&30,this will give you nohce that I(we}have pravided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insuranee Company 1VAME OF INSURANCE COMPANY P.O.Box 4070 Burlington,MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-100-60i4316-2014A 03/31/2014-03/3i/20�5 POLYCY NUMBER EFT�CTXVE DATES 973 lyannaugh Road Mil[er McCartin dba Dowling&O'Neil Hyannis, MA 026a't (508)775-1620 NAM�OF INSURANC�AGEINT ADDRESS PHONE Cape Cod&Islands Counci[Inc Boy 247 WiElow St Yat�nouthport,MA 02675 EMPLOYER ADDR�SS �� 0212 7/2 0 1 4 DATE MEDICA� T�ATMENT The above named insurer is reqnired in cases of personal iz�juries aarising out of and in the caurse of emplayment to farnish adequate and reasanabla hospital and medical services in accardance with the pravisians of the Wu�ke�rs Compensation Act. A capy of the First Report of Injury must be given to the injured employee.The em�ioyee may seleet his or her own pliysician.The reasona�le cost of the services p�rovided �y the treating physician will be paid by the iz�su�rer, if the trea�ment is necessary and reasonably connected to the work related in�ju�y. xn cases req�iring Itosnztal attention, emplayees a�e hereby no '�f'ited that fihe insurer has arranged fo�such attention at Ehe lVEARESl'AND BEST MEQICAL FACiLITY EMPLOYER ADDRESS 1� �� 7 i i`�� I �lY.�.�L� Y�Y�.