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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICEN + , rt � - A�� ; n �� w�� : .` .� , * Please complete form and attach a11 nece�s „ : e N' e ber 13 2013. i' Failure to do so will result in the re�n o a ' ica ion p c e�JEALTH EPT. � ESTABLISHMENT NAME: ' �r � " LOCATION ADDRESS: !62 � .ds L��'/ �cI TEL.#:-�d �'7'/ 9�"i L-7 � MAILING ADDRESS: �O ?1 �'i�LA- �d �. �, .t, IYl e,C �I /vr 5' � � d � � �' �X,rl��?-, ��orn � � OWNER NAME: ' i °� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: /J� TEL.#: — z7 MAILING ADDRESS:�'g !�r*` r!'l.a--_ 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 certification to tlus form. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Communi Cardio ulmon Resuscitation CPR ,havin one certified em lo ee on remises at all times. Please list t3' P �'3' � ) g P Y P the em lo ees below and attach co ies of their certifications to this form. The Health De artment will not use ast p Y P P P 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 ', an er as defined in the Sta.te Sanit Code for Food Service Establishments 105 CMR 590.000. Please attach � M a , g � �'Y copies of certification to this application. The Iiealth Department will not use past years' records. You must j � provide new copies and maintain a file at your establishment. � ^ $ � �? S"'3�r � r- i. rJ ��-eo yt,r�, 2. � �j�.` ' ` , � � �. - -��x�o�v n�-e��: -- . _- -� -_-- ____ �, I � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I � 1. �l� , �A�t-G�Qh t{� 2. ��U�L�'l- � � � ALLERGEN CERTIFICATIONS: _, � All food service esta.blishments are required to have at least one full-time employee who has Allergen certification,as � �, defined in the Sta.te Sanitary Code for Food Service Esta.blishments, 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. �d� �--2�n/'r�,•+.c,�• 2. , u I, 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-cholcing 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. 'I l. 2• ' 3. 4. RESTAURANT SEATING: TOTAL# �i-r'�e o�7'� ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMING POOL $80ea LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE IT# 0-100 SEATS $85 _CONTINENTAL $35 { NON-PROFIT $30 -�� >100 SEATS $160 _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. $225 � VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBAC�O $95 NAME CHANGE: $15 AMOUNT DUE _ $ 30.OO � *****�'!L�EA.,SE'�IJRN OVER A1VD COMPLET�OTHER SIDE QF-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 Compensati3n Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE 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(9a)days within any six(6)month period. Use of a guest unit as a residence or dwelling urut 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 srt in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,tota.l 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. P�t3L CLO�IN�: Every outdoor in ground swimming pool must be drained or covered within seven (7) days �f _ 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 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 ta 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 13,2013. 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 SITE PLAN. ` DATE:_ ��f2-�l`{ SIGNATURE: PRINT N�&Ti'I'i,E: �( � �}n.-� '`yI2/�-.t L!� Rev. 10/08/13 � � �� The Corr�morawealth ofMassachuseits �� ';��, J�� Deprartinent o,f Indrrstrial Accdd�nts Of,fice oflnvestigatiot�.s A�'R 3 0 2014 ' 1 Congr�ess Street,Su�te I00 Bostvxt,lV�A 021I4 20X 7 �#�`��-T�' ��?T. www.mass.gov%dia Workers' Comipensation Insurance Af�idavit: General Bnsinesses � Annlicanf Infurmation Please Print Le 'Y,�blrt BusinesslOrganization Name: `��N�a��/a�w�� /cnrr►� �A�S�S At1� Address: to2 0� Mn�t W �T City/State/Zip: 50,�,.� �l�ur�o�t�t,MA o?�,��{ Phone#: �08--771-��27 Are you an employerT Check the appropriate bo�: Busiuese Type(reqnired): i.❑ I am a employer with employees(ful!and/ 5. ❑Retait ar part time}.* 6. ❑RestaurantBar/Ea#ing Establishment 2.❑ I am a sole praprietor or�ership and have no �, �O�ce and/or 3ales(incl. real esfiate,auto,etc.) ennployees working for me in any capacity. [No workcrs'comp.insurance required] g- �on-profit 3.❑ We are a corporation and its officers�ave exercised 9. ❑Entertainment their rigbt of exemption per c. 152,§1(4),and we have 10.�Manu£aaturing no emp3oyees.lNo workers' comp.insurance required]* 4.� We are a non-profit organi�tion,staffed by volunteers, 11.�Health Care with no emplayees.[I�To warkers'camp.insurance req.j 12.�atk►er 'AnY applicrmt that checks boac#i must also fill art the seetion below showing ihe'v worlcers'compensstion pollcy'snformation. "If the ccuporate officxrs Lave axempted�e�selves,but We corporation hes other anployees,a worloers'cumpeasation policy is required and such an o�adon shoutd cl�edc box�i. _._ . . . I am an employer that ts provfding workers'compensation lnsurunee for my employees Below ts the poticy tnformatton. Insurance Company Nama: �� Insuxer's Address• � 4 CIL�+�#C�lp: �� I i Policy#or Self ins.Lic.# Expira#ion Date: � Attach a copp of the workers'compensation poIicy declarateon pagc(showing the policy number and eapira#ion date). FaiiUre to seeure coverage as required under Secrion 25A of MC�L c. 152 can lead to the imposition of criminal penalties o�a fine up to$1,500.00 and/or one-year imprisonment,as well as ci�il penatcies in tI�e form of a STOP WORK ORDER and a fine of up ta$250.00 a day against the violator. Be advi�d that a copy of tbis statement may ba forwarded to the Office of Investigations of the DIA for insurance caverage verification. I do hereby ceritfy der he pai�rs au�aC penalties of perjury tliut the i�'orma[tiotc provdded above is true and correc� � �Si � „- � "' � �O a � � g 2"� O,j�?etal use only. Do not wrdte in thls area,fo be completed by city vr town of,f�ciab City or Town:__ �hR�tGv'�t} Permit/License# rss le onej: ,Bo�rd af Health 2. 'Lding Department 3.City/Town Clerk 4.Licensing Boarci 5.Selectmen's O�"ice 6. er � , Cont�ct Person: Phone#: u'`b8-�3`18-223! x i2`Q� � � www.mass.gov�dia � II� I`, it