The URL can be used to link to this page

Home My WebLink AboutApplication and WC 1 �* ► TOWN OF YARMOUTH BOARD OF HEALTH ; , G°� ��c c� � � � APPLICATION FOR LICENS� �'- 1 � � JAN 15�016 "'"� * Please complete form and attach all nece�s�d , fi�er��b De ' mber IS 01 � ' Failure to do so will result in the re�u�of,�o�,.�ppl'ic�it�°i ac T ESTABLISHMENT NAME: �C.� TAX ID: LOCATION ADDRESS: TEL.#: � �- I r ?✓" MAILING ADDRESS: E-MAIL ADDRESS: C� �Q...Gp , OWNER NAME: � CORPORATION NAME (IF APPLICABLE): 1VIANAGER'S NAME: TEL.#: " 3`� MAILING ADDRESS: U� (}t� p POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as re ired by State law. Please list the designated Pbol erator(s) and attach a copy of the certification to this form. . - ------ 1 _ _ , - -- - — 2- _ -- _ — � _. - -- a. - -- - � _ _ Pool operators must list ' imum two employees currently certified in standard First i Community Cardiopulmonary Resuscitation havmg one certified employee on premises at I times. Please list the employees below and attach co ' s of their ions to this form. The Health artment will not use past years' records. You must ovide new copies and maintain a file at your pl e 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.�1�-L ,��d� � I PERSON 1N CHARGE: ' Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �� U�� 1,�� 2. � "�"� 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 mai tain a file at your establishment. ' 1.' N 2. �'�� c�� 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 a d maintain a file at your place of business. 1. ��CS �� G c� � � 2. 2 T' E�(��5� f 3. O 4. � RESTAURANT SEATING. TOTAL# "�J � --- LODGIN �--- __ --_ (1FFif''Ti' iTCTi' ��]�:�_— . -� - -- G. --- --- - � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER IT# i� CABIN $55 _MOTEL $110 _ $55 —CAMP SWIMMING POOL$1 l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1 l0ea. I FOOD SERVICE: L CENSE REQUIRED FEE P I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE IT# 0-100 SEATS $125 �� CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 ZCOMMON VIC. $60 TG, —��8 =WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 ! LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM T# <50 sq.8. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 Z<25,000 sq.ft. $150 �,3 =FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ 3 35•O O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � I r r _ . � j l 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 S�GNED,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: ' 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. 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 to 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. � OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. , from Janu 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN its run annuall �'Y NOTICE: Perm Y THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABAND APPRO ED BY TOHE BOARD OF HEAL HGPRIOR ! EQUIPMENT,ETC.),MUST BE REPORTED TO TO COMME CEM NT. RENOVATIONS MAY REQUIRE A SIT N. � SIGNATURE: DATE: � PRINT NAME& TITLE: � U Rev. 10/01/15 � ; I � ' � NOTICE NOTICE � F i To v To M W � r a EMPLOYEES 4��K EMPLC�YEES � �!'�M Ne�� s The Cor�l.monwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - hrip://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30,this will give you notice that I (we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSIJRANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF INSURANCE COMPANY 014005030830116 � 1/Ol/2016 - 1J01/2017 � POLICY NUMBER EFFECTIVE DATES Schofield Insurance Services, 1102 Main Street Millis,MA 02054 508-376-54E NAME OF INSURANCE AGENT ADDRESS PHONE# ' Keltic Kitchen 415 Main Street West Yarmouth,MA 02673 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE � MEDICAL fiREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the ' injured empioyee. The employee may select his or her own physician. The reasonable cost of the ser- j vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and � reasonably connected to the wark related injury. In cases requiring hospital attention, employees are � hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL, ADDRESS TO BE POSTED BY EMPLOYER � 4f (6 f d G