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Home My WebLink AboutApplication and WC � a TOWN OF YARMOUTH BOARD OF HEALTH �`��d�� APPLICATION FOR LICENSE/PER�I� ,: �� fi � � r, • , r�t� � � [U15 j """ * Please complete form and attach all necessary dc�i�le : e S 20�`S. Failure to do so will result in the return of y�r ap��i�ticr�p �:HEALTH DEPT. ESTABLISHMENT NAME: TA ID: - LOCATION ADDRESS: n�.�. „A-- 2 EL.#: � MAILING ADDRESS: E-MAIL ADDRESS: S � L�'�CA�-I"• OWNER NAME: es:�:��. CORPORATION AME (IF APPLICABLE): MANAGER'S NAME: `�j �`Q�, n rv� 6 i sl't,tr,o TEL.#:��39�2�33 MAILING ADDRESS: ��,...,�� . POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poo Operator(s)and attach a copy of the certification to this form. -- - --- - --- 1 _ - --- - -------------2-- — - �.� - ----____ ____ i � Pool operator ust list a minimum of two employees currently certified in standard First Aid and Community ' Cardiopulmon esuscitation (CPR), having one certified employee on premises at all times. Please list the employees below attach copies of their certifications to this form. The Health Department will not use past years' records. You st provide new copies and maintain a file at your place of business. , 1. 2. 3. 4. ' i �FOOD PROTECTION MANAGERS - CERTIFICATIONS: All foo service establishments are required to have at least one full-time employee who is certified as a Food ' Protectio Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ; Please atta copies of certification to this application. The Health Department will not use past years'records. You must p vide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHAR E: Each food establishm t must have at least one Person In Charge (PIC) on site during hours of operation. - - - ; • - - - -_ -.__- _ -- -- _ _ - -----z�-��.�� i ALLERGEN CERTIFICAT NS: � AIl food service establishment are required to have at least one full-time employee who has Allergen certification, ' as defined in the State Sanitary de for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach ' copies of certification to this appli ation. The Health Department will not use past years' records. You must provide new copies and maintain file at your establishment. 1. 2. '; HEIMLICH CERTIFICATIONS: All food service establishments with 25 sea or more must have at least one employee trained in�the Heimlich Maneuver on the premises at all times. Pleas list your employees trained in anti-choking procedures below and attach copies`of employee certifications to this rm. The Health Department will not use past years' records. '' You must provide new copies and maintain a le at your place of business. �; 1. 2. 3. 4, ; RESTAURANT SEATING: TOTAL# ----- — -------__ --- ---�� f��F�;�------- LODGING: --- ---_`-----__.-- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P �fI�# � _B&B $55 CABIN $55 1MOTEL $110 <<0 3 � I� $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 _CONTINENTt�. $33 NON-PROFIT $30 >100 SEATS $200 _COMMO�1 VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 � LICENSE REQUIRED FEE PERMIT# LIGENSE 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 $I 10 � NAME CHANGE: $15 AMOUNT DUE _ $ !/O.00 ' � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' II 1 4 ADMINISTRATION � . Under Chapter 1 S2,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: T'he 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.varmouth.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 sampl�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 IRE A SI PLA DATE: Io� / /� SIGNATURE: PRINT NAME&TITLE: �� f7� Rev. 10/Ol/15 ' � � # � i i NOTICE N � NOTICE TO " TO v � � � � EMPLOYEES � �= EMPLOYEE5 , �W '. / y ; O�M SV� � � The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS � 600 Washington Street, Boston, Massachusetts 02111 i 617-727-4900 — http://www.mass.gov/dia __ __ . - _ __ - -_ � � _ __ _ -- ---- � As required by Massachusetts General Law, Chapter 152, Sections 2�S�c 30; fhis will give yoa notiee tt�a� ---- -- I(we) have provided for payment to our injured employees under the above mentioned chapter by imsuring v�nth: ' THE TRAVELERS INSURANCE COMPANIES � NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY 1 (IEUB-2493L94-5-15) 06-01 —15 TO 06-01—16 POLICY NUMBER EFFECTIVE DATES ;' BRIGHT AGENCY INC PO BOX 424 e; ' m� MILFORD MA 017570424 j �_ NAME OF INSURANCE AGENT ADDRESS PHONE# � �— SEASIDE RENTAL ASSOCIATION 135 SOUTH SHORE DRIVE � o.� � �� SOUTH YARMOUTH �� _ MA 02664 i '°�___EIv�_PLOYER ADDRESS �� —_ _ - -_ ____—-- _ --- _ o_ � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE �� MEDI�AL TREATMENT � 'The above named insurer is required in cases of personal injuries arising out of and in the course of �— employment to furnish adequate and reasonable hospital and medical services in accordance with the �= provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the �— injured employee. The employee may select his or her own physician. The reasonable cost of the services = provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably '— connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS o�58B W2aP,�o2 TO BE POSTED BY EMPLOYER