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Home My WebLink AboutApplication and WC� . ,�:�, � ��.��, ��l�'_ �_ M.�7� °� TOWN OF YARMOUTH BOARD OF H�,AI�� ::- � � � APPLICATION FOR LICENSEIPERMIT-2011 Q�� '� ��(�� ''°' � � �78'��-�� 8 �� * Please complete form and attach all necessary, ocuinen�ts by ec �t�ber°�,�8�1. '' Failure to do so will result in the return of your applicatitac� �x�-- j ESTABLISHMENT NAME: �� i' /�'J TAX ID:�� _ i LOCATION ADDRESS: � - TEL.#: � -,3��P��t� MAILING ADDRESS: �S�*�r�• ; OVVNER NAME: 1 CORPORATION NAME (IF APPLICABLE : C� _ - � .L/l✓� MANAGER'S NAME: �S'�� ,�/ ,� TEL.#: J ' ' �� MAILING ADDRESS: B�P-:'"~ � �,�. ��j� � �� j�-�—da�S POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a co�y af the certification to this iorm. 1. 2. Pool operators must list a minimum of two einployees cun ently certified in basic water safety,standard First Aid aud 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- FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined 'ui the State Sanitary Code for Food Service Establisluneuts, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You mu rovide new copies and maintain a file at your establishment. 1. 2 PERSON IN CHARGE: Each food establislune t must have at Ieast one Persou In Cl�arge (PIC) on site during hours of operatioii. 1. 6 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trauied 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 ne�v copies and maintain a file at vour place of business. 1. 2 3• 4. RESTAURANT SEATING: TOTAL # LODGI\G: CIFFICE USE ONLY LICENSE REQUIRED FEE PERMIT?? LICENSE REQUIRED FEE PERNIIT� LICENSE REQUIlZED FEE PERl�1IT� _B&B S55 _CABIN S55 _1�OTEL S55 _n`INN S55 _CAMP S55 _S��`L�rI;�IING POOL S80ea. _LODGE S55 �TRAII,ERPARK 5105 _�kT3IRI,pOOL S80ea. FOOD SER�'ICE: I � LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERi�IIT� LICENSE REQUIRED FEE PERib1IT� _0-100 SEATS S85 _CONTINENTAL S35 _NON-PROFIT S30 ' _>100 SEATS S160 _CO'_�IlVION VIC. S60 _W�IOLESALE S80 RETr1IL SERVICE: ' —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�IIT� LICENSE REQUIRED FEE PER�IIT.� LICENSE REQUIRED FEE PER'�IIr� <50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD S35 �<2�,000 s ft. S80 �b�l ' q• �PD;'.�b.( _.FROZENDESSERT 540 I TOBACCO S�5 y��J�..6Z� ': �AVIE CHA\GE: S15 ' AMOUNT DUE _ $ t'35,OO i **"**PLEASE TUR\�O�ER A\D COIiPLEI'E OI'HER SIDE OF FOR�1 + **,�** j � { � '-�' � ,. �' 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 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 f TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be � limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. 4 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 sha11 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. , i POOLS � � POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i 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 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 swimming pool must be drained or covered within seven(7)days of closing. I FOOD SERVICE SEASONAL FOOD SERVICE OPENING: � 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. � 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.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 ofHealth. _- --- --- — OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO C4MMENCEMENT. RENOVATIONS MAY REQUIRE A SITE P AN. . DATE: ��7�/O SIGNATURE: PRINT NAME&TITLE: Dlanfl2 LeCkek �icensina Coordinat�r io�o6>io 1 ,-�.�--_ I �\ � ; - Department of Industrial Accidents ' Dffice of Investigations d 600 Washin�ton Street ; Boston, �A 02I11 M 6Y ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses AppIicant Tinformaiion Please Print Leaiblv � Business/Organization Name; CVS/pharmacy# �� . � . � � Acidress: Qne NS Dr,f�lail Drop 23062A � TJ_ City/State/Zip: WOONSOCKET, RI 02895 phone #: 401-765-1 S00 Are you an employer? Check the appropriate box: Business Type (required): 1. X� I am a employer with .3� employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � �;fice alzd/or Sal�s (incl. rea:estate, auto, etc.) einployees 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 worlcers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insuraiice req.] � I�•❑ 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'compensation policy is required and such an organization should check box#l. I am;�n employer that is providing workers'compensation insurance for my employees: Below is the policy information. Ins�lrancP �or..par.,Nar.:e: NEW HAMPSHIRE INSURANCE COMPANY Insurer's Address: �0 PINE STREET � � City/State/Zip: NEW YORK,NY 10270 Policy#or Self-ins. Lic. # 6506290 Expiration Date: 01/01/2011 Attach a copy of the worlcers' co�►pensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 $25Q.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 aEo hef•eby certify;.under•the pains..¢nd penalties of perjury that the information provided above is true and correct Si ature: -_-- -' Date: � . � Phone �: �C�f`=�� '— �'``.�� ' ` � Official use only. Do not write in this area, to 8e completed by ciry or town official. City or�'own: Fermit/I.icense# - - - Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other � Contact Person: Phone#: www.mass.eov/dia � f i E . . . . CM/SIp�'�/� -_ .��..� One CVS Drive � Woonsocket, �tl 02895 � GEC 1 G 2010 � � � __� � . �� . � s_ ___. _�.�,,. � December 3, 2010 Dear Sir/Madam: Enclosed please find completed application(s) and/or invoice(s) along with payment in the appropriate amount to cover the cost of the renewal for the CVS/pharmacy store(s) in your area. Please note anv chan�es made on the application re�ardin�trade name and or mailin�address, and include store numbers on invoices and nermits as indicated on the application to insure correct nayment to the proper store. Please send the permit(s)/license(s) and anv future renewal aAl4lications for this store, with the store nacmber on it, to my attention at: One CYS Drive, Licensin�Dept, Mail Drop 23062A, Woonsocket, RI 02895. After receiving the licenses, I will make the necessary copies for my files and forward the originals to the stores for posting. If you have any questions, please contact me at 401-770-5772 or by fax 401-652-0608. Sincerely �' , �,;a � ,.�;� ,=�' � � ,� � � Dianr�e L. Lackey Licensing Assistant Legal Department