The URL can be used to link to this page

Home My WebLink AboutApplication and WC1 I � � G3i�'�i�u�n�� ► TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICE � I'�2 ��,_ ,�, j�;,�,� � Cl L�.�1� � * n��'��s: Please complete form and attach all ne „.�s o��arr�er�t by �ec mb pT. Failure to do so will result in the ' `urn��r�p� on E�TABLISHMENT NAME: ��-k i 1�(i..��P_•� - TAX ID: LOCATION ADDRESS: 22Q �l��sZ �.0 y�Y�� D2.b �'} TEL.#: ¢oS 77�g��o . MAILING ADDRESS: E-MAIL ADDRESS:� �jir�1�0 �c �-/-sr�rvlG;�,,[a,�, OWNER NAME: : CpRPORATION NAME (IF APPLICABL : �4 5�' ,,� ��r � ` MANAGER'S NAME: 7�Go Su �� TEL.#: �� 71Sr !�lGa. � MAILING ADDRESS: �_� 1 ��s�,'rr r�. vt�1�dA- C`1?./�] � 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 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. L 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 Aealth Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. ' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. ; 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. ; -� 3. 2� ! 4. RESTAURANT SEATING: TOTAL# ZOO OFFICE USE ONLY ' LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _B&B $55 _CABIN $55 MOTEL $110 i —I� $55 C�P $55 SWIMMING POOL$I l0ea. LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. i+00U<SERVICE: � -LiCENSE REQi,IIREI) FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PF.RMIT# - 0-100 S�11TS , $125 ` CONTINENTAL $35 NON-PROFIT $30 . ;��100 S�ATS $2b0 �j • �COMMON VIC. $60 ��2 —WHOLESALE $80 °�<. d. �� ._ RF ,�I gER�v'l�E: —RESID.KITCHEN $80 LI�N�1��iE(�UT�f�EI3 FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $SQ: >25,000 sq.ft. $285 VENDING-FOOD $25 „<25,ObQ sq:ft. $150 ` -�'—' =FROZEN DESSERT $40 =TOBACCO $110 NA ME CHANGE: $�s AMOUNT DUE _ $ 2��O D *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** C 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 f � 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. j 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. � i 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.�armouth.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: of Health. he Board Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have pnor approval from t 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. � MOTEL OR POOL (i.e., PAINTING, NEW ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , DATE: - d'��16 SIGNATURE: � � pRINT NAME& TITLE: �4�1 I7;�-� >�C n � � � Rev.10/O1/15 i , � ��'� TASTY-1 pP ID:ST '`�i�,�R�� CERTIFICATE OF LIABILITY INSURANCE ��6 � TFq8 CERTIFlCATE IS FSSt�D AS A NATTER OF MlFORqATION�ILY AND CONFERS NO RIGHTS t�ON 7HE CERTIFICATE HOLDER.TFdS CERTIFICATE DpE$NpT qFF�tYpT1VELY OR NEGATIVELY/�AIEND, EXTEtb pR ALTER TME CpYERAGE AFFpRE�D BY THE POLI(�E$ BELOW. TF�S CERT�ICATE OF INSURANCE DOES NOT CON87TiUiE A CONiRACT BETNIEEN THE ISSI�Ki INSURER(S),AU7HORI�D REPRESENTATIVE OR pRODUCER,AND 7}IE CERTIFICATE FlOLpER. �'ORTANT: N she oertFRpte Iwlder��f AQaiIONAL NSURED�the PolieY(ks)muat 6e w�dorsed. N SUBRQGATION IS WAIVED,subjoce m the terms and eondilions�the PolicY,ceryin PuRcies msy re�irc an erxloraemeek, A�an tlds eertiFkaee does not oonfer riphts to the csrtltieaM hader in lieu of sueh s weooucEa S�Sa��rre�� h} �� .506-746-0030 ;506-747-3036 PfYmaufl+�M/►02960 �& N �wrtowo cov�oe wuc r wsue�re�:AmGuard Insuranoe Com y r�weEo T�BuHet Irte NsueER B: Jun in Zhang ; 228 Main Streat r�sua�e c. W Yarmoutfi,MA 02673 raurtER o: YqURER E: I, NBUNER P: COVERApE$ CERTIFfCA7E NUMBER; REVISION NUMBER: j 7HIS 13 TO CERTIFY 7}IAT THE POLICI£S OF INSURANCE U3TED BELOW HAVE BEEN ISSUE4 TO THE MSURED NAMEQ/�VE FOR THE POLICY PERIOD INOICATED, t�TWITHSTANDING ANY REQUIREMENT,TERM OR COND177pN OF ANY CONTRACT pR OTHER DpCi111�NT WITH RESPECT TO WHICH TFNS CERTIFICJ►TE MAY BE ISSI�D pR MAY PERTAW,THE WSURANCE AFFOR�ED BY THE PpLIC1ES DESCRIBED HEREIN IS SUB.�CT Tp ALL THE TERM,S, I', EXCLUSIONS AND CaJDIT10N$pF$UCM ppt,IGES.UMIT3 SHOWN MAY HAVE BEEN REQUCED BY PAID CLAIM3, L7R... 7YPE OF W811RAMf� . .... . .....VpLICy MNlER .. .... ... �Yii,B . ..... . .. Cl1YMF.RCIAL @EIERAL LIABILI7Y EAGH OCCURRENGE S CLAIMSMAbE �OCCUR PREAtlSES Ea ocwnerce = AffQ EXP( ore person► i PER9(X111L R qDV INJURY = GENL AGGREGATE L�MR APPLIES PER: GENERAL AQCiREGATE f POtICY❑JEGT �� PRODUCTS-COMP/OPAGG t � OTHER: � . . { . /1UTOYO9�LE LIABlfIY E�S�NGLE LIMIT = ANY At1T0 BODt.Y INJ1IRY(P�Parsm) S ALLOWNE6 SCHEDULED AUTOS AllTUS 800RY INJURY(��U f WREDAUTOS µ��p�� R E ; . i IlIIBNEW W8 �UR EACHqCCURRENCE S E1fCp8 W�8... CWMS-MADE AGGREGATE � . . �D RETENTION � : � . WOIlIfERB C011PEWA710N AIO E11RL4Y�8'LI�LlTY Y/N x STAME ER A ��E��xEcurrve � �� R2wC74ZS88 03/25/Zq18 09l25JT477 E.LEACHACCmENT s 100, (MndYory N�!W) E.l.DISEASE-EA E1�1-OYE _ �� M��s,doscaNMa u�der DESCRI�MIO�N OF OPERATIONS 6ebw E.L.DISEASE-P�ICV LHdfT = � � . DEBCRM11W1 QF PPERA710M8!LOCA710W9 J VEHICLES(ACORO 1M.Adilia�s�1 Ram�rlu Beh�ii�,m�Y 4ea11Klyd i wen ap�c�it nqniad) . .. 22$Maln�reet,W YarrtwuN�MA CERTiFICATE HOLDER CANCELLATION SHOULD ANY OF TF�ABOVE DESCRIBm POLICES BE CANCELIED BEFORE Town of Yarmouth T�+E ��'� owre n�rtE�, No'�e w�.� ee DELJVERED ui 11A6 RouW 28 ACCORDANCE YYITH 7t1E POL�Y PROV�ql�. SouM Yarmouth,MA 02664 MII}IORI2ED REPREBENfATNE --� ��......��- g 198&2014 ACORO CORPORA770N. All rights resanred. i ACORD 25(2014In1) The ACORD neme and bpo are reyisbred marka of ACORD i i � f f i ��.._ s� � ` � The Commonwealth of Massachusetts �� Department of Industrial Accidents i Office of Investigations � ' l Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia _ Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name:�� U ��,�Pf , ' _� � Address: � 2� i rn �--� City/State/Zip: Phone #: �'v}3 —�� (— �-�� ) 'O Are you an employer?Check the appropriate boz: Business Type(required): 1.� I am a employer with��employees(full and/ 5. ❑ Retail or part-time).* L€'S�• 6. �'RestaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � O�ce 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 a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ 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 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: � Insurer's Address: ' City/State/Zip: i Policy#or Self-ins. Lic. # Expiration Date: I Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpirallon 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 that the information provided above is true and correc� Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official � City or Town: PermitlLicense# 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