The URL can be used to link to this page

Home My WebLink AboutApplication and WC , � � .�.. _ •�;�^� TOWN OF YARMOUTH BOARD OF H� L� _ " - ' = APPLICATION FOR LICENSElPE �'� 2 `�� . �� ., � � �e � ��` � �� h�� 0 � �U11 * Please complete form and attach a11 necessary doc�ent ecembe 1 S 0 0 � :�. Failure to do so will result in the return of your application pack 'e"�x��-'� h��;��a�#� ESTABLISHMENT NAME: f-�CE�cJr�l� fWpi��, ;N/✓ TAX ID: LOCATION ADDRESS: A'G/ �vl��tl g� TEL.#�5-0�, A'k-�8!2 MAILING ADDRESS: 9(0/ M�+'N a T Qc�= y�MDU7ff Ma- n.2�G 1L OWNER NAME:___ /V � M T�Sr CORPORATION NAME (IF APPLICABLE): /t/ � /V) /Z�L >�2us� ' MANAGER'S NAME:_ N��f}- ,�,fv S✓,v� TEL.#�S�) �t$ -g�ji� MAILING ADDRESS: 9G/ .�1rt1-i�tJ �T" S�: y�e.tiou�"If- �•J/� c�9�'�t� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) aiid attach a copy of the cei-tification to this foi7lz. 1._NGrf�/� �cJS�ivf{ 2. Pool operators must list a mulimum of two employees curr•ently certified in basic�vater safety,standard Fu st Aid a.ud Community Cardiopulmonaiy 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 ne�v copies and maintain a file at your place of business. '; 1._J�/Cr�i A- .cLc/5✓�t/ff 2._Cf�l 2r'S��F�t� K%�t� 3- Ir/l�r�f�•� .�F-r�s�iv ft 4. Mi.v� ,�C�'Fc i FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined ui the State Sauitary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must pro�Tide new copies and maintain a file at your establishment. I. 2, ' PERSON IN CHARGE: Each food establislunent must have at Ieast one Person In Charge (PIC) on site duruie hours of operation. '; 1. 2, , HEIMLICH CERTffICATIONS: i All food seivice establishments with 25 seats or more must have at least one employee trained ui the Heunlicl� ', Maneuver on the �remises at all times. Please list your employees trauied in anti-chokuig procedures below aud attach copies of einployee certifications to this foini. The Health Department will not use past years' records. You must provide ne�v copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERi�IIT?? LICENSE REQUIRED FEE PER:v1IT� LICENSE REQUIRED FEE PER'�IIT� _a�.B sss _caB�rr sss ��orFL sss (-6 _iNN S55 _CAMP S» l S�4L'vI1v1ING POOL S80ea.�� LODGE S» �TRAILERPARK S10� ��iIRLpOOL S80ea. ��,�3 ' FOOD SERVICE: LICENSE REQLTIRED FEE PERNIIT� LICENSE REQUIRED FEE PEIZ��IIT� LICENSE REQUIRED FEE PER�IIT= _0-100 SEATS S85 �CONTINENTAL S35 ��(o _NON-PROFIT S30 _>100 SEATS S160 _CONL'�ZON VIC. S60 V�HOLESALE S80 RETAII.SER�TCE: —RESID.KITCHEN S80 LICENSE REQL�IRED FEE PER1jIIT� LICENSE REQUIRED FEE PER�IIr.� LICENSE REQUIRED FEE PER'�fIT# _<50 sq.ft. S50 _>25,000 sq.ft. S?25 VENDING-FOOD S3� _45,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S» �a��c��E: sis AMOUNT DUE _ $ ��G , C��'�: *****PLEASE TL12:�OVER A\D C0�IPLETE OTHER SIDE OF FOR�T***** r i � . i ADMINISTRATION r'� � 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' F Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � CERT. OF INSURANCE ATTACHED � OR I � 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 ofresidence elsewhere. � Transient occupancy sha11 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 De�artment to schedule the inspection three(3)days pnor to opening. PLEASE NOTE:People are NOT allowed to srt m 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 I thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FUOD SERVICE SEASONAL FOOD SERVICE OPENING: E All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the � Health Department to schedule the inspection three(3) days prior to opening. j G I 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.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 ofHealth. i 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 RESPONSIBII.TI'Y TO RETLJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQLJIRED FEE(S)BY DECEMBER 15, 2010. i ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR PO L (i.e., PAINTING, NEW EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED B HE OARD OF HEALTH PRIOR r TO CONIMENCEMENT. RENOVATIONS MAY REQUIR A SIT LAN DATE: ��- �" - �� SIGNATURE: � � � PRINT NAME&TITLE: — ��/ /� � � io.�o6�io � E � E � � t � •/'• r'.► � '. The Commonwealth of Massachusetts Departnent of Industriat Accidents > �'f N��iIMi ` 600 Washington Stree� f"`Floor Boston,Mass. 02111 Worlcers'Compeesntioa Iasara�ce Affidavit:Baildiag/Plambieg/Elech�ical Co�tractors - -- -�ti�� r narue: /zi�F�`.i.!i L+f�/� /Vf�T71/i' !OU N address: �(D� M�1 %D(/ �T� ' �ty�Ti�-Q�c7 � rN state• �t/1 f1' zip. .7�/'�l [� nhone# (S Og j ��l `Z� ..�.yT work site location(full addressl: ❑ I am a homeowner performing all wa�k myself. Project Type: ❑New Canstructi��R�nodel ❑ I am a sole proprietor and have no one worlcing in any capacity. ❑Building Addition �I am an employer providing wakers'compensatia�for my�pioyees warking on this job. coma�v nme: i�i�'�N T �.✓�Ilr`� � �O�1/2 1 NN �dd�ss' ��n/ t��//V �' T ' ' � � : o� y�,e�,� u��-r �#:r s�g.��t� - ��r�. � � - -i c, , . �� .�' . ��. _ : , .... � r� ,..�,. . ❑ I am a sole praprietor,geaerai costractor,or�omeo�raer(cirdt one)and have luted the contr�ctots ylistsd below wta have , tbe following workeis'cflmpensation polices: , commar'ame- addtess: c3ty; Drore#: � N ' ...�. <.� � �,:�.� ' ... . . . .. ... ' ' . N . � �Y�: �: �i . . . .. . .. � . . �� . .. . . ,. � . . .._�, . . . . ,r" . . , . . .,.� , �, Fa�are�s xeQ+e awera�e aa neqtir+ed uder 3a�D 2SA ef MGL 1S2 cu lad b tte irpakMa�f cr6�i�a1 pnaNks�f a 8�e�p b=1,SN.N atdl�r o'e yean'Imprboaaeat as weY as dv�pe�aitles ia the foret sta 3TOT WORK ORDER aad a Sae etS160.N�day a�aiast me. 1�de�staid Nnt a c�py of tYia�tatemcit e�ay 6e ferwarded b�e O�ce ot3�atl�s af f�MA ter t�v�erage ver�alMa. !do benby cerajy xnder tlie ps onl ofPtrjrr�y'Hi�t tlbe iwfor�nedo�Srovlded aba►+e is d�re arid comrt Signatnre � � Date .� � q - // Ptint name �['��'/�- .Z}-t/�/Vr�- Phone# c9� � $ 1 ' e�cial ese only de not waite�this area to be ceaPkted bY dly er tnva e�cial cily ar te�vu: permiN�oesse# ❑Baiding Dkpartmcat �� ❑ehc�ic if�1e re�eme is reqmed OSdutocn's O�oe QHe�De�atdewt ceuact peraaH: phose#; � t,��a s�-ma+) i � . I � � ' NOTICE N � � NOTICE TO � a TO _ � EMPLO�.'EES << EMPLOYEES .� / y� O,�M S�� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 -- http://www.mass.gov/dia As re uired 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 msuring vv�th: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY P.O. BOX 1450 ' MIDDLEBORO. MA 02344-1450 ADDRESS�F INSURANCE COMPANY (6S60U6-0694C06-5-10) 0$-16-10 TO 08-16-11 POLICY NUI�IBER EFFECTIVE DATES �.._ n� DOWLING & 0 NEIL INS 973 IYAtW10UGH ROAD �� HYAl�II S MA 02601 � NAME OF INSURANCE AGENT ADDRESS PHONE# � BRENTWOOD h10TOR INN INC 961 ROUTE 28 � 5 YARNIQUTH �� MA 02664 �� '� EMPLOYER ADDRESS .� � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY} DATE � MEDICAL TRE�iTMENT � The above named insurer is required in cases of personal injuries arising out of and in the course of a� employment to furnish adequate and reasonable haspital 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 employee. The employee may select his or her own physician. 'The reasonable cost of the services � � provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably ' connected ta the wark related injury. In cases requiring hospital attention, employees are hereby notifed that the insurer has ananged for such attention at the NAME OF HOSPITAL ADDRESS �seo� W20P1G02 TO BE POSTED BY EMPLOYER