The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD .y� ,;E T � f: _ . '� f�� S � � � APPLI C A T I O N F O R L I C E N S E/P E `,�,�� .� �; D k l: O Z U 1 5 '`"" * Please complete form and attach all necessary�cu y_ e�''�' �r 0 S. ' Failure to do so will result in the return of your application pa c t. DEPT. E�TABLISHMENT NAME: v � TAX ID: � LOCATION ADDRESS: /�� -OId cu�C� . QyY�?o�- 0�6�HTEL.#: 0�,.3q�:SG MAILING ADDRESS: S E-MAIL ADDRESS: hu�resh �L q �c Od- Com OWNER NAME: CORPORATION NAME IF APPLICABLE): ��.5 R�� CUr 1VIANAGER'S NAME: TEL.#: " --�6 -q� Q-� 1vTAILING ADDRESS: � Ccn�,S r�. �' �Grn'1 � � PbOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P4o1 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 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. 1. 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 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. ._ � __ _ _ __ _ ___ - -- ----____ _- -- _ � _ _ __ --, 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. 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. ', L� 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 $I10 ' INN $55 CAMP $55 SWIMMING POOL$ll0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. 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: � LICENSB REQUIRED FEE PERMIT# LICENSE 1tEQUIRED 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 .�7��Z� NAMECHANGE: $is AMOUNTDUE _ $ 2�0.00 ' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION • ' �` Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal f 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 1 Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: � YES � NO F � MOTELS AND OTHER LODGING ESTABLISHMENTS i 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. e :___ ____ _ _ . _____ ___ _ � 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: i 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 sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen j Dessert Permit until the above terms have been met. y � 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 II 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:�.�'s` �� SIGNATURE: �Yd�� PRINT NAME & TITLE: :�h��3!-�,. P� �(�Wf1�e�) (' ��1'�� Rev. 10/O1/15 � The Commonwealth of Massachusetts ' ' � � _ - Department of Ind�cstrial Accidents ' Office of Investigations t ' I Congress Street, Suite I00 Boston,MA 02I14-2017. www.mass.gov/dia _. Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: �c�.Sh � �� r� �A `T�cv,��au�- �� Address: �.�2 J� � ��ca.,�� i.� � ., 6-�f City/State/Zip: �-�W+riY1�A��-� 6��1 Phone#: �°�3�� Are you an employer? Check the appropriate bo�: Business Type(required): 1.❑ I am a employer with � employees(full and/ 5. �Retail o�nart-time�*_ 6. ❑RestaurantBar/Eating Esta.blishment - — - — _ ---- � __ _ - ---—-- — 2. I am a sole proprietor or partnership and have no --- -- _-_- -- 7. ❑ Office and/or Sa1es(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. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.�Manufacturing no employees. [No workers' comp. insurance required]* 11.� Health Caze 4.❑ VJe 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 corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: �. . � ��,5 u�Aq'LG� �.�,P. Insurer's Address:� S� �O�''F"`T��r 1� , ��`"-==�'I ' City/Sta.te/Zip: /� 1�� d/';�'� r �� '3 q Policy#or Self-ins.Lic.# O I�O U OS� �C� ��I I�� Expira.tion Date: I / 4 � 1�� I 6 Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ______ Failure to_secure coyerage as re�c uired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalt�es 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 ofperjury that the information provided above is true and correct. Si�nature• ��1'� �ww( Date: /°�r�� Phone#: r 6 ` � 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 , � .4co" CERTIFICATE Of LIABILITY INSURANCE °"�;`�"�'° ,°s' THIS CERT�ICATE IS ISSUED AS A MATTER OF INFORMATION QNLY Alit CONFERS NO RIGHTS l�ON THE CERTIFICATE ttOLDER THIS CERT�ICATE DOES NOT AFF9iMATiVELY OR I�GATfl/ELY AMEIm, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOW. THIS CERTIflCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IS5U�1(3 �ISURER(S), AUTHOR�D liEPRESENTATNE OR PRODUCER,AND THE CERT�ICATE HOL.DER ' HYIPORTANT: N the certilica�e hoWer is an ADDITlONAL INSURED.the Poi�Yl�es)rrwst ba Mdars�d. H SUBROGATION 15 WAIYED,sub�t�o� ths terens and cond�ions of the poRcy,oertain policies may require an endors�nfant. A atatement on 1Ms cerlificab does not conter righEs!o tl�e c�rbifica�e hotder in liwa of such�ndors rRooucse G.H.Dta»Instr�ce Agency,Inc. . Deborah Hathawey P O BOX 330 � . «��`� F� No�:(`�32�3243 215MAIN STREET �� BUZZARDS BAY MA 02S.�Z i ,�r�pe�c cov�ae�� wucs �� A, MA RETAILERS U00000 IN3URED Yashr�Corp dbe To�wn Ha�se New�Paresh Patef iNsuRat s: 1�d Old Tawn House Rd IN&lRER : Soutli Y�mouth,MA 02664 INSURBt D: tNBtJRER E: INSU ER F: COVERAGES CERTIFlCATE NUMBER REVI810N kUM6ER THS IS TO CER7IFY 7ti4T T}-E POLIGES OF INSt�1NCE LISIED BELCJW HAVE 6EEN ISSI�D ln TFE I�SI�ED N4MED A�ONE FOR TFE POLICY PERIQD IP[11CA1'ED. NOlWITt�STAN�NG ANY REQUFENEM;'fERM OR Gq�DIiION OF AFJY COWTRACT OR 07FER DOCIAuENT WIIH fiE�ECT'tt�WHCH 7tfS CERIIFIGA7E NWY BE ISSIED OR MAY PERTAtN,7tE It�ANC�AFFOF2DEd BY 7FE POLIqES DESCRI�D tERFJN IS SI�JECT'it�ALL 1FE 7EF'iMS, EXCUJSIONS MD OOPDI?IQH15 OF StX:FI PaLICXXE3.UM75 SF�IC7U1M MAY HAVE BEEN REDIK:ED BY PAtD G./�IMS. Trn�oFnrauwwce noucvNu�r Poucv rwucr uMrrs OOMM�tdALGE1�ERN.L1A81L11Y EACHOC�BJCE S GYAqdS-MADE �OCCtJR $ A�D� w�e $ PB2SONAL&ADV ri�1RY S GH�1L AOGRBGATE UMi APRIeS PB2: GB�ERAL ACiORBGATE $ POIICY ❑„��,^- �LOC PRODUCI'S-OONPI�OP MaG S O'iFEf� $ AUTOMOBGE LIAB9.ITY $ ANY AtlTO 80DY.Y IWIRY(Fb►Person) S ALL 01M�� BOD�Y fPl1lRY(Pl�r aoddettt� 3 HI�AUfOS q�� PROPB7fYDAMAGE E S UMBRELLALWB OCCU2 EACHOCCIRRBJCE S �� CLAIMSMADE AppRB3ATE S 0� REfHJf10M S S A rwr��s�r��►�oN m40006a��s��a rn�rzcrts rnjmrzots AND BQPIAYERS'W4BIU7Y ��p�� N❑ N 1 A EL E/1CH AOC�BJf S J�,�O (Mandatory In NH! EL DISEA.SE-EA ENt�LOY� S �,� U yes,deaaibe under DE�CR�fION OF OP82ATIOIyS bebw EL OISEA9E-POLICI'I.IMT $ �+� DESCRIPTiON OF OPERATIONS/LOCATqNS/VEf11CL�(ACORD 101,AtldRbnsY ReauHcs Seheduls,may bs atfaehed N moro apace is roquketl) CERTIFICATE HOLAER CANCEtLAT�N Fax#:(508)39&0636 SHOkJID ANIf OF THE ABOVE DESCRBED POLICIES BE CN�ICELLED BEF�ORE TawrfafYarrnot�tltBuiltinig Depertmenk THE EXPNtATqN DATE Tt1ER�OF, NOTK:E WM.L BE DEL�ED M 1146 Rt� , ACCORDANICE WI7'H THE POLICY PfdoNlS10NS. Sotth Y�tnoufh,MA 02684 AUTMORI�D R�REBENTAINE � �e�� 119�-2014 ACOIZQ CORPORA7'IOM. A9 riphts reserved. ACORD 2b(ZQ14/01) The ACORD rattne and bgo are ng�ber�ed marks ot ACORD