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HomeMy WebLinkAboutApplication and WC `r�i CsC��I�E'�T � � � TOWN OF YARMOUTH BOARD OF H TH � � APPLICATION FOR LICENSE/PERM -2016 U�-� ` 4 2��5 ' * Please complete form and attach all necessary docu ecemb r 1 �9`� DEPT. ' Failure to do so will result in the return of your application packe . E5TABLISHMENT NAME: t�� TAX ID• � LOCATION ADDRESS: �9 d �. . TEL.#: U � �'3� � MAILING ADDRESS: Q 2- E-MAIL ADDRESS: O�UNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: t TEL.#: -3 �331 MAILING ADDRESS: �'Q o � S• POOL CERTIFICATIONS: • The pool supervisor must be certified as a Pool Operator,as required by Sta aw. Please 1' he designated Pool Operator(s) and attach a copy of the certification to this form. 1. �+PFr'�c�rzti�'� �.a 1 t't__1'�C"` ��e.�i"� _ _ - �. ---- __ ___ Pool operators must list a minimum of two employees currently ce ' ed in stand First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified empl ee on prem' s at all times. Please list the employees below and attach copies of their certifications to this . The He Department will not use pa years' records. You must provide new copies and maintai file at yo lace of business. , L � ��s'v1 W�1� o� -� 2. � 3. � 4• FOOD PROTECTION MANAGERS - CERTIF TIONS: d All food service establishments are re uired t ave at lea ne full-time em lo ee who is ce�ified as a Food q p Y , Protection Manager, as defined in the State itary Cod or Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this lication. e Health Department will not use past years'records. You must provide new copies and ma' ain a file our establishment. 1. 2. 1 �� PERSON IN CHARGE: �'�� Each food establishment must ve at least e Person In Charge (PIC) on site during hours of operation. � _ _ l - _ __ _-__ _ 2. �/' ALLERGEN CERTIF ATIONS: All food service esta shments ar equired to have at least one full-time employee who has Allerge ertification, as defined in the S e Sanitary de for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certific ion to this lication. The Health Department will not use past years' records. You must provide new ies and m tain a file at your establishment. � l. 2. � 1y /S HEIMLICH CERTIF ATIONS: All food service es lishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the mises at all times. Please list your employees trained in anti-choking procedures below and attach copies of ployee 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. � RESTAURANT SEATING: TOTAL# - - --- n--a�c�* r rc-��-^�:��� _ __.. --- - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 / MOTEL $110 ! INN $55 CAMP $55 SWIMMING POOL$110ea. � _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: • LICENSE REQUIRED FEE PERMIT# LICENSE 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 $110 ' NAME CHANGE: $is - AMOUNT DUE _ $ /l0 .O O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � _ . ADMINISTRATION � � E 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 WORI�ER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �� - , CERT. OF INSURANCE ATTACHED • � � I' OR � i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewa�or issuarice of your permits. PLEASE CHECK APPROPRIATELY IF PAID: E 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 aggtega�.of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or •�- dwelling unif slla� not be considered transient. Occupancy that is subject to the �ollection of Room Occupancy ""�� -F�ac�ise, as defined irr�Vi.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. . 3 ' � ' 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�.nd opened. POOL WArT-ER�'rES��: �'l��ater must be tested for pseudomonas,total coliform and standard plate count � by a State certified 1� , 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 � Cl�S1ria. _ _ _ 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. - CA,T�RING POLICY: Anyeme wl?�,o�aters 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.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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service esta.blishment is prohibited. _ _ I 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: t C �.,� SIGNATURE: � PRINT NAME & TITL : � Rev.10/01/15 ( �_ : " ' � The Commonwealth of Massachusetts Department of Industrial Accidents �, Office of Investigations ` ' 1 Congress Street, Suite I00 Boston, MA 02114-2017 . - www.mass.gov/dia jWorkers' Compensation Insurance A�fidavit: General Businesses � A�plicant Information Please Print Le�iblv . Business/Organization Name��e �hc� �;�� Address: ��a��P � City/State/Zip: � . t0 Phone#:�bg-�RQ-�,3IS Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Reta.il _ __-nr parixime�.* _ _ ____ 6. ❑ RestaurantBaz/Eating Esta.blishment �,/ - - -- --- - _ � 2.I� 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 o�cers 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]* 1 l.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.�ther � O��� *Any applicant that checks box#1 must also fill out the section below showing their workers'compensaflon policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensarion 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: Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). __ Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a I -- _ _ _ --- -- fine up to$1,500.00 and/or one-year imprisonment,as we as civi pen ies m e o-� rm b��STC3P�VORi��n"r`__� r_ ______; of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�ce of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and pena 'es ofperjury that the information provided above is true and correct. Si ature: � Date: ��- ��" t� Phone#: '�D '��I�� �3� Official use only. Do not write in this area,to be completed by city or town officia� 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