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Home My WebLink AboutApplication and WC� ~ �. � TOWN OF YARMOUTH BOARD OF HEALTH ' V� ° � � � APPLICATIONFORLICENSE/P�R�?I� ",� O1�; °'"�;� �� .� 4 �� . ��,.- �`°" * Please complete form and attach all necessary doc E^ n y, "c r 1 S 201 S. ' Failure to do so will result in the return o�yo�a�i " et. HEq6, ESTABLISHMENT NAME: � T D: • LOCATION ADDRESS: /34 i'rlr�i.v [7��r�- Vi9+tzw�► ��t"�T'EL.#: ,S'p��G� 33L^ MAILING ADDRESS: Sn►...� G�.�G?S" E-MAIL ADDRESS:�j,n,/�rf 0��,,5" Vist/�,� OWNER NAME: . [_��Lr,� �/�� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �( �� , ,,. TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certifed 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. � _ ___-- --- --_ _ - ----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. i. C'�a�l=5 �°��_ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. _. �,/��.,�Iz 5 � � 1.-�.�.� �.� • _�.___-�- ___ 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 m�st provide new copies and maintain a file at your establishment. 1. �' �/G/`��s � �!�-�L v�. 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 1� "f"" f I� . ' ,___._ -___._ .__..___-____. .. �T7f"�T iTC�T Allii �7 . . Zr�i.. ' 1 ._- _-_'--_-__-_ _ __�_.__ LODGING: " LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INt�} $55 CAMP $55 SWIMMING POOL$110ea. �' _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-]00 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 VEI�DING-FOOD $25 _<25,000 sq.ft. $150 �FROZEN DESSERT $40 � _TOBACCO $110 � NAME CHANGE: $15 . AMOUNT DUE _ $ 225 •OO ' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** .� � i ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of a�y�license or permit to operate a business if a person ar company does not have a Certificate of Worker's ' Cpmp�s�tibri Insurance. THE ATTACHED' STATE WO1t,KER'S COMPENSATION INSURANCE j , AFFIDAVIT MUST BE COMPLETED�1ND SIGNED, 0� � . � 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: 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 q 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. � 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 zo the catered event. These forms can be obtamed 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 � 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. � w � 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 T BOARD OF EALTH PRIOR TO COMMEN MENT. RENOVATIONS MAY REQUIRE SIT . � DATE: f SIGNATURE: ' � PRiNT NAME & TITLE: ��G��z�S � ��- '� Rev. 10lO1/IS i � The Commonwealth of 111assachusetts w Department af Industrial Acci�tents �� Of'fre af Inves�'igations � I Congress Street,Suite 100 ; Boston,MA 0211 d•2tlJ 7 � - www.�nass gov/dia Warkers' Compensation Insurance Affidavit: General Businesses Apt�licant Inforr�ati4n , Please Print Le�iblv Business/Urganization Name:�_._ Charles Clark D B A Hallet's Store Address: 139 Main Street Git�•/Staie/Zip: Yarmouthnort Ma.02675 phone�:�08 3(2 2402 � Are y'ou an employer?C6eck the apprapr'iate box: 8usiness Type(required): 1.❑ I am a employer with empioyees(full ancL' S. ❑ Retail or part-time).* 6. �j �.estauranv`FssrtEating�stabiishrnent 2.❑ T am a sole proprietor or partnership and have no 7, (�Office andlor Sales{incl.real estate,auto,etc.) employees working for me in an� capaciry. g � �on-profit (`Vo�orkers' comp.insurance requiredj 3.❑ �G'e are a corporaiian and its officers have exercis�d 9. ❑ Entertainment their ri�ht a€exemptian per c. I52, §l(4},and we hav�e 14.[�Manufacturing na emplayees:[No workers' comp. insurance xequiredJ* 1 l.[� Healfh Care 4.❑ We are a non-prafit organization,staffed by volunteers, with no employees. [No workers' comp.insw�nce req.j ' 12.(�Uther *Anq applieant that checks box�l must also fiii out the section below showing their workers'compensatioa p�ticq-information. : **if the corporate officers have exempt�d themselres,but che corporacion has other emplo}ees,a��orkers'campensa�9on policy is Fequired and such an � oreanizarion should check box#L I am an employer that is providing workers'compensaiion insurance for my emplvyees. Below is the poticy informat�on. Insurance Campany Name: LOVEQllIST- MURRAY INS A'GGY INC Insurer's�ddress: 23611tiAIN ST --: Cit}r,'State�Zip:^ �EST DENNIS MA 02670-0038 Po(icy�or Self-ins. Lic.# SBP 1065339 Expiration Date: 12/13 f 2017 Attach a copy of the worken' compensation policy declaration p�ge(showing the policy number aed expiration date). Failure ta secure coverage as requirecE under Section 25A of MGL c. 152 ean lead to the imposition of eriminal penaIties of a fine up to S I,SOU.Ot?and�`or ona-vPar im�+risonment,as well as civil,penalties in the form of a STOP Vi'(�RK URDER and a fine of up to�250.�0 a day against the violator. Be advised that a copy 4f this statement may be fonvarded`to the+�ffice of Investigations af tt�e DIA far insurance coverage verification. I do hereby cert�fv,under the pa' s pen 'e jury that the information provided aba e is tru and correct. Si,�nature: . a • g" Phone#: Uffzcial use only. Do nat wrue in this area,to be completed by city nr town o�ciat City or Town: `PermiULicense# Issuing Authority(circle one): 1. Board oF He�lth 2. Building Department 3. Gity/Towa Clerk 4.Licensing Board S.Selestmen's Office 6.Other Cantact Person: Phone#: wH�v.mass.eov/dia