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� � TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/PERMIT -201 ��.��� DEC , � 2015
...• * "`�"�`, "�4 ��i�'�`_
Please complete form and attach all necess 'c�o�u,�a���its�y Decezn er 1 S 01 S.
Failure to do so will result in the ret , o�yo�r application p�c t. DEPT.
; _�
ESTABLISHMENT NAME: •-���GS f�A�k..� TAX ID:
LOCATION ADDRESS: (¢ 0�(M U o(�' TEL.#: 3lsa-G 0
MAILING ADDRESS: �
E-MAIL ADDRESS: �- '
OWNER NAME: a. a
CORPORATION NAME IF APPLICABLE):_ .�(ci,�ks o�l-b u,�. i�•
NIANAGER'S NAME: �0 i'LG�.�! G1�0.-�il TEL.#: .�p A'�y(D- 1,.3gS
MAILING ADDRESS: �(¢ I �.Ot�r_ Ge� y0.1�MA J�tAD� , {till%1 ��"b 7S
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.
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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 IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �D n r��r�a.�.. 2. ►�I�x �
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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. ,
�. `,�a ��..��� 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.
i. � i � 2. �� o n,a.. �r-(�..
3. n. 4.
RESTAURANT SEATING: TO AL# �3 '
i
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OFFICE USE ONLY ,.
LUllG1NG:
--___ _--
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $110
_�� $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PE I7'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 �l�-E� CONTINENTAL $35 NON-PROFIT $30 i'
_>100 SEATS $200 �COMMON VIC. $60 � � =WHOLESALE $80 j
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I
_<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 _ $ !8 5-OO
*****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
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 I
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
_ a . .�_ .. : . _ ___
E
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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.
� .._ ;,�_.. _ �,_- � _.��.�__ �� -�-.�..v� . �.. . � � -
, ,.�_FOt�I) SE�2VIC� , . � : �. _ _�� ���_T _
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
obtamed 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 i
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 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.
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: Z S SIGNATURE:�/����/(- �
PRINT NAME&TITLE: �I O f1 G� A��-� D���'
Rev.10/O1/I S
� ' � The Commonwealth o Massachusetts
� f
Department of Industrial Accidents
` Office of Investigations
' 1 Congress Street, Suite I00
Boston, MA 02114-2017
.`.. , www.mass.gov/dia
Workers' Compensation Insuraace Affidavit:General Businesses � � � -`� �'��
Applicant Information - - - .-- Please Print Legiblv
Business/Organization Name: G l
Address: �
b�
� City/State/Zip: G�,( p p� Phone#: �lJ g �(,c.a �¢(p�'(�
Are y an employer. heck the appropriate boz: Business Type(required):
1. I am a employer withy�r employees(full and/ 5. ❑ etail
. > _ _
or part-time).* � 6. " RestauranUBarlEafing EstabTisfi�ient— '
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(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]* 1 l.� Health Care
4.❑ We are a non-profit organizaxion,stafFed by volunteers, '
with no employees. [No workers' comp. insurance req.] 12.0 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 providiixg workers'compensation insurance for my employees Below is the policy informatlon.
Ins"uranc�Cninpany Name:�{b���(�
Insurer's Address: � �OI'� ��t(��L
City/Sta.te%Zip: U I � 0 a��0 1
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Policy#or Self-ins.Lic.#. _I I a'�S�I aI� Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date):
Failur�to secure covexage as required un�r 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"`a�eivii pen�lties in the form of a STOP Vi/ORK 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
Inv�stigations 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 correct.
SiQnature: �/'�/'��� Date• ���/�� :
Phone#: ��� �J(Q a" R�
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
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NOTIC� �� NOTICE
� T'� TO
" EMPLQYEES ° EMPL4YEES
a
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The Commonwealth of Massachusetts
DEPARTME�T OF �NDUSTRIAL ACCIDENTS
600 Washingt�n Street,Boston, Massachusetts Q2111
617-72'1-4900-http:/lwww.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I (we)have�rovided for�avmQnt to our in�ured em�lovees under the above mentioned cha�ter by
insuring with:
__ Ar6ella Protection Insurance Compan
NAME OF INSUIiANCE COMPANY
_ 1100 Crown Calc�n Drive, Qaincy,MA 021b9
ADDRESS UF INSURANCF.COMPAI�Y
#9124871215 12/04/2415-12J04/2016
POLICY NUMBER EFFECTIVE DATES
Izag�rs�c Gr��Itc��ra�����c�tc�y �3� t2r�ute i34,Sout�t �enrtis, �1 Q2b6{l
NAME OF I1vSURANCE AGENT ADDRESS
Slack's Outback Inc 161 Main Street, Route 6A,Bldg 2
DBA Jacks Outback II Yarmauthport, '_YIA 02675
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATIO'�I OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of persona�injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
�rov�.c�Q�,s e�f the�Vork�r's Co�ge�sat�c�rt A�t.A cvpy Qf thc�irst.R��rt c�llrt,��,•ry�t�st be g#ven tc�the
injured employee. The employee may select his or her own physician.The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insarer,if the treatment is necessary and
reasonably connected to the work related injnry.In cases requiring hospital attention,employecs are
here6y notificd that the insurer has arranged for such attention at the
Name�f Hospital Address
TU BE POSTED B� EMPL4YER