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Home My WebLink AboutApplication and WC ....,�.,.�.�, � � � TOWN OF YARMOUTH BOARD OF HEAL'��I �� U SE` ( � ' � APPLICATION FOR LICENSE/PE I : 0 3 ,,w p�C 1 � "'�':' F � . �„ �, � �p� f p * Please complete form and attach all necessar'�r . c y Dec mb �0��.;,��- i Failure to do so will result in the return�your applicahon p�ket:-�� -�-�- i � ESTABLISHMENT NAME: TAX ID: ` LOCATION ADDRESS: v�— TEL.#: MAILING ADDRESS: �w�k-- � �! OWNERNAME: /rF �� "' CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: v 1'ZU) TEL.#: � � r � � MAILING ADDRESS: '� ��- o�� u� � Gw POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �. Pnn� R��ratc�r��_�]'1C�- G� GQ� of _ �rt��ca�on tc� ��_f�T'T11�___1_____ � �--�--�-.--�h�-�-_ - --- - - -_-__-�_ ,--�--_,_-___--- --�=-_—; � �_ _ - ---- - 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. � � i ; ; FOOD PROTF,CTION MANAGERS - CERTIFICATIONS: ; All food service establishments are required to have at least one full-time employee who is certified as a Food I 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 ___ . ... t _ .. _-J�`.�i r y , r_ - _---=---�-=- -- _ -- — ---- --- --- -- ----. --- . , -- -- -- - _ � _ i Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. ' 1. 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 I attach copies of employee certifications to this form. The Health Department will not use past years' records. ' Xou must provide new copies and maintain a file at your place of business. i 1. 2. � 3. 4. i RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' i _B&B $55 _CABIN $55 �MOTEL $55 �� j f INN �55 CAMP $55 _SWIMMING POOL $80ea. ', LODGE $55 TRAILER PE1RK $105 �WHIRLYOC�L �fTea. -- — — _ � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 �CONTINENTAL $35 3—0 {.J NON-PROFIT $30 � >100 SEATS $160 _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. $225 _VENDING-FOOD $25 _<25,000 sy.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $i s _ AMOUNT DUE _ $ g,o.O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � I I I 1__ -�_ _ . _ — — _ � 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 Certi�icate 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 f � ; __ __iVIt3'�'EI�S''A1�TY3��T ; I,D�GIl'�1�LS'T�i3LIS�iMENTS __.._ _ _ 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 i 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 seascx}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 axe 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 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: _ _9i�id��,-e�td�r-seati�g-��iterl�vaitre.�s�ervice),must have prior apnrnva�l.fromth�B.a�f Health` _ Q�JT�DOR��'i�Il�:---_ _ _ _ _=-_ -- 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, 2012. 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 M NT. RENOVATIONS MAY REQUIRE A SITE PLA . � � DATE: 1� � SIGNATURE: � PR1NT NAME& TITLE: !�c ��h �"�"``� ��I�"�G '`, Rev. ]0/09/12 � M' � � The Commonwealth of Massachusetts Department of Industrial Accidents � , . Office of Investigations 1 C'ongress Street,Suite 100 • Boston,MA 02114-2017 { I www.mass.gov/dia Workers' Compensafion Insurance Affidavit: General Businesses Aunlicant Information Please Print LeEiblv Business/Organization Name: ��s- �c-c��- 11G C.�ZL��4 Address: '� a � ; �d `��'' �° J G ; City/State/Zip: r Phone#: / j _- -=-- _ - • - � �'��.��cre,��k --��- _ - - _ _ , . .� - . , .��, , . . �. .... � . : � _ `_- 1.�I am a employer with /0 employees(full and/ 5: [�Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ 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 officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4),and we have 10.❑Manufacturing ' no employees. [No workers' comp. insurance required]* ll.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informa on. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation 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 u the policy infarmation. � Insurance Company Name: ' � Insurer's Address: f City/State/Zip: � - -- _-�1icy�a;�3f-in�:�ic.# - - _ - ----___---_-�E-�-�ati�r.-�� _- -- -_ _ �_ - _ _ , Attach a copy of the workers' compensation policy declaration page(showing the poIicy number and expiration 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,SOU:00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ! of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of � , Investigations of the DIA for insurance coverage verification. i I do hereby certify, der th pains andpenaltdes ofperjury that the information provided ab ve is rue and correct. � I Si ature: � N. Date: /'✓ � �� ; Phone#: $ -�a� ��'�� Officdal use only. Do not write in this ared,to be completed by city or town officiaL , City or Town:_��9,2�►Mil"�'?i� � _Permit/License# � �i g or ' cle one): � � ' 1.Board of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office � . I Contact Person: Phone#: �8-=3 4�Q-�-�-3( x f�-�� ! . www.mass:gov/dia � , . � TRAVELER� . . � - wo�K�s cxHi�►no� � . . �', .n...: . . M� • EMPLOYERS LIABILtTY POLICY 7YPE AR IN�IATION PA�GE WC QO 00 01 � A) Pt�1.IC1r�+IUMBEi� (sfalB-5648824-7-12) . . PEMI-12 INSUHER: TFE TRAVELERS INDEMtIIY COI�PAN1( ' �. � r�oo c�: �� . . INBURLD: pp�p;� - . BASS RIVER REC�ATI�+1 INC �NSDN YOI�IG 8 DOMMS IliS 7� St'�TtH SFR�RE DR�bE . . , ;;P. O ,BI,7DC 1$$ . BASS RIVER MA 02684 FIARMIGI PORT MA 02G46 ' , Ineund M A c�ORPORATION . Other w�ork pleoe�and fder�iR�tbrt numbara are sho�m In the�chadula(s�a�ed. . 2. Th9 pdiCy p6rlod Is irortl v7-13-12 t0 0?-13-t 3 12:01 A.M.e�ttt9 Mwr�d's mWinp u�ness. S. �A. WORICERS C01iPENSATION INSURA�NCE: Part Ons af t#�e pCl�l►a�lles t0�he Wartt4rs tbmpeneatlon Law of'ths e�s�e(s)Ife�ed h�e: MA � .� . . . �� " � B. EMPLOYERS LIABIUTY INSUHANCE: Part TM►a of ttw poII�Y appliee�o w�ork�e�ch�liebed In � �em 3A The iln�a af a�r II�Ry w�der Part Two ar� ��Y��Y�Y��den� s 600000 E�ach/1txldent . : ' � �oY��'Y bl►�lesma� s 500000. Pol(cy�Imk � ��Y��1�rY bI►�� 00000�Esd�Employee � C. O7'HER STATES INStJt�A� Pa�t Three af tbe pd�Y applies Lo��.�any,ll�ted here: C01IEitAL� REPLAt�D, BY EN70RSENENT 1�I�CC �O 0� 06A . .� . � . '� D. ThN po11Cy Indudes theee er�merrts errc!achacl� � � - - a� SEE LISTItJ� OF EI+DORSEIrENTS - EX7EN�IOIiE.� IfrFO PAG� . a� : � �. The prerrtlum for tf�s pol4y w�tw de�errMned by ou�i�u�uds af Rule��lor�.R�and F�tlnp ' � Pler�. AN r�qlJlted 1nfOrmatlOfl�stlbjec�tD�+er�lC�1 and ChenpY by audR�D b9 n�ie AMMJALLY. . �A1E OF ISSUE: OB-14-12 PS ST A�SIt�I: MA OFFICE: ORLAFD� INDIjS AFF 161' . PRODt10El� �NSON Yt7UVG a DO�I1d5 INS - �. � aotss