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Home My WebLink AboutApplication and WC �._� , . �N t � � TOWN OF YARMOUTH BOARD OF HEAL� � APPLICATION FOR LICENSE/�'E '; r ;- 4 ��'� ° " ' ' ` �c�; 'i �[�?,3 � • '� �" ` � l; * Please complete form and attach a11 neces�a�y d '� t y; n� 4 �. � m ; Failure to do so will result in the return of your application ' ' ESTABLISHMENT NAME: Gs ��b�3` ID: --�� - LOCATION ADDRESS: ��,' , p- m��,r� Sr/�T�� ti .��,� �.�'l� TEL.#: S''�`_?,2,��6 , MAILING ADDRESS: -�'�t,r,�' �s ,f�� b2 �3 ; E-MAIL ADDRESS: � � OWNER NAME: CORPORATION NAME (IF APPLICABLE): ��1�/�i� .��'t.� MANAGER'S NAME: � !1��L /2,t��Jj TEL.#: �S�R�7,3?�T�`j� MAILING ADDRESS: S'�v;� ,d.,c „��F" 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 copv of the c�rtifr��tiQn tQ�s fs�--- -- - --� - l. �� . �� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and ; Community Cardiopulmonary Resuscita.tion(CPR),having one certified employee on premises at ail 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 �le at your place of business. l. � I� 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. /U 2. � � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. ' , - _ _ _ ,��/� 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 maintain a file at your establishment. 1. dV /i� 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 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. N 2. �/ •P�/1 3. 4. RESTAURANT SEATING: TOTAL# 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 _WHIRI,POOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 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 �T —�,�' —FROZEN DESSERT $40 �TOBACCO $95 ��l , NAME CHANGE: �i s AMOUNT DUE _ $ l 7 5•-O C� , '*****PL�A3E'1'URN 4VER AND COMPLETE OTHER SIDE OF FORM***"*° � �� ADMINISTRATION � _ . ; Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issua.�ce 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 l� NO � A�i(?TELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCU,PANCY: 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 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 thereafter. POOL CLOSING: Every outdoor in ground swirnming pool must be drained or covered wi#hin 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: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,�reparation� or displav of any food�roduct a r�ta_il or food service_P_s_tahlichmPnt;� n.-�h.h.ta.� ___.. 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. R�NOVATIONS MAY REQUIRE A SITE PLAN. DATE: �Z,J I SIGNATURE: —� PRINT NAME&TITLE: ,� �i�� ' Rev. 10/08/13 r f i �' � The Commonwealth ofMassachusetts � . _ Department of Industrial Accidents Office oflnvestigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�plicant Information Please Print Legiblv Business/Organization Name:�� 12,��'�;�'"�,J_ L�� jV L Address: ��f — /�/�rl v�'� ��' �� i City/State/Zip: . Phone#: �p�-- Z�S`'� 1-��OG Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with_�employees(full and/ 5. �'Retail C�j /VU/l�s�/GLss �� __ _ or par��i�e}:� _-_,___ _ --- - __ _ _�_._.�RestauranbBar/Eating��stablishment 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 c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care ' 4.❑ We are a non-profit organization,sta.ffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensarion policy is required and such an organizarion should check box#L I am an employer that is providing warkers'compensation insurance for my employees Below is the policy information. ' Insurance Company Name:_ �d'l�L"i�. �i /Z(TUId ��/��jJ/�S ' Insurer's Address: �� ... � .��,�1,� ��j � f'��12 City/State/Zip: �c�'`g��/[�st'�. E� 1' �� ! Policy#or Self-ins.Lic. # ��C D(� I �S-d� Expiration Date: D y��'Z�2�17 , Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). ' Failure to secure coverage as-r�uir�u un��r�e;,ti�rr 25A of 3vI��: i 52�an t�au��.h��ng�sition-af�rimiza3 p�za3ties�f a---- „ fine up to$1,500.00 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 do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. i Sig�ature: Date: �Z �� l� Phone#: ��g � �.�—"'`/�O6 �� S G1�� 7 "��c�� .; Official use only. Do not write in this area,to be completed by city or town officiaL � i i City or Town:y�C/t�t0�7�! Permit/License# ' Iss ' :it� circle one): ' .Board of Health . Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Ot er Contact Person: Phone#:�B�34R.-��3� k/25�/ wwwmass.gov/dia (