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Home My WebLink AboutApplication and WC � ND S ! i� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICF��P�$M� -2416 ��, ;.A , �,�.� - � z �� '""'" * Please complete form and attach all r��cess dQc �e�its�y� ecember 1 S 2015. �.. � � Failure to do so will result in tl��retu�n of yaur,applica�'on�d�e�H DEPT. I - ESTABLISHMENT NAME• - � .l AX ID: � LOCATION ADDRESS: � TEL.#: S� � � MAILING ADDRESS: d E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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 certi�cation to this form. _ _ - -- -_ - _ ._ _ _ L. ____ __- Pool operators must list a minimum of two err�ployees 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 Sanitaty 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. l. 2, P�SON IN CHARGE: • Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �---- -a--��:___ .: :__-_ :�__.�.____ - � -_ 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 far 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. HEIIVILICH 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 mast provide new copies and maintain a file at your place of business. ` ; 1• 2. 3• 4. RESTAURANT SEATING: TOTAL# --------- r fiuz��l��-__——�- — _ _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE,REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 I� $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 PERM[T# 0-100 SEATS $125 _CONTINENTAL, $35 NON-PROFIT $30 � >t00 SEATS $200 _COMMON VIC. $60 _WHOLESALE $80 ' —RESID.KITCHEN $80 � RETAIL SERVICE: _ I LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j <50 sq.ft. $50 �� _>25,000 sq.ft. $285 VENDING-FOOD $25 ! �<25,000 sq.ft. $750 Z _FROZENDESSERT $40 _TOBACCO ' $I10 -' ; I NAME CHANGE: $15 AMOUNT DUE = $ �'ja.QQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r R . _ e 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 1NSURANCE 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: i 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. i � 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 f thereafter. � .�- POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. _ _4._.,_ . - � - -: . _ _ _ - >. FOOD �ERVICE . j 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 � 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: SIGNATURE: � . PRINT NAME & TITLE: Rev. 10/O1/IS � The Commonwealth o M � ; � f assach usetts ' Department of Ind�cstrial Accidents j `� Office of Investigations ' ' 1 Congress Street, Suite 100 Boston,MA 02I14-2017 _ ; www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses � _ . . � ApAlicant Information Please Print Le�iblv Business/Organization Name:(��,� � , Jyt,�� (j�� `_ �� Address: �� _ � - City/State/Zip: �e#: — Are you an empkryer? Check t�e appropriate boz: Busine�Typa(r�quired): 1.❑ I am a employer with employees(full and/ 5• ��1 - . * 6. �Restata.urantlBar/Eating Establishment 2. I am a sole proprietor or partners-Tiip an�have no- - -- - - —__ - - - ----- employees working for me m any ca.pacity. �' ��Or Sales(incl.real estate,auto,etc. [No workers' comp. insurance required] g• ❑Non-profit 3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12•❑ Other *Any applicant that checks box#i must also fill out the section below showing their workers'compensation policyinformation. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should checkbox#L I am�an employer that is providing workers'compensation insurance for my em loyees Below is the pol' information. :° Insurance Company Name;_�9��`,//�� /�/��'��1�' J � ��' ��"� - �/� � � Insurer's Address: %�Gl ��'--- �� -�;,�- ,�Qa> �J City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: ��.�/ � Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpira o 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 1,50 .0 a.ndTor one-year impnsonm as wen-as�rvi 5 __ of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c , nde�x t e paans and enalt�es of perjury that the information provided above is true and correct. : �--- ; Si ature: Date: � � � Phone#: Official use orely. Do not write in this area,to be completed by city or town offtcia� � City.or Town; Permit/License# j Issuing Authority(circle one): , j 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office � 6.Other ' l f Contact Person• Phone#• � � www.mass.gov/dia � : {�=�\ _ . � �'�.�E NC�TI�E TO � TQ r ; �MPL4�EES q � EMPLC�YEES w �, � . ----- ___ _ _ _ _ _ _ �- . -- �'he Common�ealth of l��Iassa� us , �. etts ; DEPARTME�TT OF INDUSTRIAL ACCIDENTS } Congress 51�eet, Suite 140, Bo�ton, Massachusetts 0�114-2017 617-727-4900 - http:/iwww.state,ma.us/dia As required by Massachusetts Generai Law, Chapter 152, Sec�ions 21,22&30,this will give you notice ' that I (we)have provided for gayment to our injured emp�oyees under the'above-men�tioned chapter by i � _ 111SUd'112�Wlt�l: - MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS pF INSURANCE COMPANY 014000500089116 1/O1l2Q16 - 1/O1/2017 P�LI�Y��ER EFFECTTVE DATES Cove Risk Services, LLC Pfl Box 859222-9222 Braintree, MA 02185 $pp_790_gg� NAME OF INSURANCE AGENT ADDR.ESS PHONE# Sand'N Surf Gifts,Inc. Route 28 South Yarmouth,MA 02664 EMPLOYER /j� .. //U��DRESS -_ _ _^� �� _ __, - -__:_:—�:.__ (� - � EMPLOYER'S WORI�RS' CO NSA ION OFFICER(IF AN� DATE MEDICAI� fiREATMEIVT The above named insurer is required in cases af personaI injuries arising out of and in the course flf employment to furnish adequa.te and reasonable"haspital and medical services in accardance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. 'The empioyee may select his or her pyvn physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer,if the ireatment is necessary and reasonably connected to#he work relateci injury. In cases requiring hospifal attentian,empioyees are hereby notified that the insurer has arranged for such attcntion at the