The URL can be used to link to this page

Home My WebLink AboutApplication and WC � ► TOWN OF YARMOUTH BOARD OF 9 � �° G��, f � � APPLICATION FOR LICENSE/PE . ,�� t; �� '� � z�� ..,.• * rlease complete form and attach all n�cessary do en ~ - 3 201 S. ' Failure to do so will result in the return of your application packet. HEALTH DEPT. ESTABLISHMENT NAME: — 3 c rn T ID: — � LOCATION ADDRESS: 'oZ m ct� �, � �r� TEL.#: �'CS�'�9` ' 7�.5� MAILING ADDRESS:�O c� o o a E-MAIL ADDRESS• R - T � w��'� • Co+�1 OWNER NAME: �� Qc� ��'r�- �� CbRPORATION NAME (IF APP ICABLE : �G�oo S 4 c� v�� MANAGER'S NAME: � � gc rTc.. T L.#: �o�'- - /�S�. 1VfAILING ADDRESS: a X o S So 4 r ►+1 a� � G l. PbOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designa.ted Pool Operator(s) d atta h a co of the certif cation to this form. � _ -_ � ��E�.-�--��?'�� - �_.�_ __ 2 _ _- ---- _ ____ _ — _- -- --_._ __ _ _ 1. 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. I 1., � ` �q�l `"C �i !'{`��i 2. �o�` l�Qf1 U��4' �� 3. 4. FbOD 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 I PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. ----�:--------_ --__-�_-- _ �._ __ - 2: __ _ _ _ ___ __-- __- ALLERGEN CERTIFICATIONS: A�1_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. 1. . 2. HEIMLICH CERTIFICATIONS: • All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 1VLaneuver on the premises at all#imes. 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' reeords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ----- ----- ----- OFFICE USE UNLY ---- _ ----------- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE T# _B&B $55 CABIN $55 / MOTEL $110 � —I� $55 CAMP $55 =SWIMMING POOL$I l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $i l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 1CONTINENTAL $35 :��(� NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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. $I50 =FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $�s AMOUNT DUE _ $ 255.o0 *****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 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. 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 COMMENC MEN . RENOVATIONS MAY REQU A SITE LA . , DATE: �0� � � S� SIGNATURE: e PRINT NAME&TITLE: � ` ��-� c �� F�'S` r'�' Rev.10/O1/15 � The Cc►mmomvealth ofMa�saehusetl,s . Depariment oflxdr�rial Accidents O.,�ce o,f'Im�estigations , 1 Congre�s Stree�Suite IQl1 Bosto�y MA 02II�2017. www�gov/dia Workers' Compensation Insnrance Affidavit: General Basinesses Apt�licant Information Please Print Le�ibiv Business/Organiza.tion Name: ��o o s�.�1� �,,,t, ��3�. �e �scp p��'�,� Address• �t��7 �o��e. 0`��4' �O QoY. tOS�f f -- C1�ISffit�Zlj�: ..�a �r wt v c� �,� ��(.�G'� Phone#: �O�^to' �"`�- 7/J,.� �n employer?Check�e aPPi'�Priate boz: Bosin�s TYP�t��): � 1_ I am a eznployer with � e�nployees(full aadl 5• ❑R�l ; or part time}.# ` e�so��a� 6. RestaurantlB _. - _ ---- — ❑ 1Baz/F.stingFstablishme.nt 2.�I am a sole --- — F�Pnetor or partae,iship and�iave no---—� 7. Office andlor Sales incL real __ — lo wo far me ia an _�`-_- --- � ��°'�,l �P Y� �8 Y�riY- 8. Q Noirprofrt ` [No workers'comp.�ce required] 3.❑ We are a coiporation aztd its officers have exea�cised 9. ❑Ent�tainme�t their zigt�t of elcemption per c. 152,§1(4},and we have I0.(�M�ufacturing no�loyees..[No workers'com�.insurance required]'� 11.�Health Care " 4.❑ We are a non-profit organizatioa,staffed by volunteers, �b�� with no anploy�s.[No workeas' �mp.insurance req.] I2.(,�,Other— 'A�r a�ppficant tha�checl�bon#1 must also fill art the sedifln below showing the�wa�ers'oo��P��Y��- �sIf the oo�poratc officeas have e��lves,but the coiparation has othr�emplopees,a w�s' � oiganiz�ioci should check box#i. �P��Y��ffid such ffi i - i 4 I am an e�rrployer that is p wo conrprais�ion in.vu au�c�e fo �ry r.�oyue� Betow is the pqruy iRforn�O�r, Insluance Company Name:��t�i�4� '�� t,r�.� �,, , . — . . Insards Aadr�ss: J(v �o��•� c.�- S' -� I - � � . . -� � City/:�p: � ; i K e 3--Q a.c s e.4�� t g?p� I Palicy#or Self-ins.Lic.# S � �C-.�d`7 �� Expir�i��: � a2 /�O Attac�a copp of the workers'compensatioa policy dedaratian page(s�owing the poiicy aumber�ad ' t�a dste). � Fatlure to sec�n�e covr.�age as raluired und�cr Se�tion 25A of MGL c. 152 can Iead to#h�impositian df cximinai penahies of a fine up to�1,500.�and/ar one-year imprisonment,as we as ties in e rm of a TY3P-WORKOR73F,1�and a�'ne— of up to 5250.00 a day against the violator. Be advised that a copy of this statemeut may be forwarded to t�e Office of Investigations of the DIA for u�urance coverage verificatioa I do heiebJ' � f at the informat�on pmv�iJed above i's trae carrrct � Si fo� l %,,j Phone#: ��d�— 9 7— /r�.�o2 - (?,ffrcial use o�rly. Do not write in tlYis areq to be co�ld�ai by cit�'ur taKrn offic�at City or Torva: Permi#/Lice.nse# Issniag Anthoriiy(cirele one): . 1.Board o#Health 2.Baikiing Uepartment 3.CityfFown Clerk 4.I.ieensing Board 5.Sdectmen's O�ce br Uther Contact Person: p�ane#. vvww.mass.ffiov/dia