HomeMy WebLinkAboutApplication and WC �� . �
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`' � � � TOWN OF YARMOUTH BOARD OF HEALTH
� APPLICATIUN FOR LTCENSE/PERMIT-20� �✓�JA� �� .� �
*Please complete form and attach all neces i�a�en�s y�Dece �OQ.ttr�� •
Failure to do so will result in the r�p�'�ou�r apph�ation p .
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NAIVIE OF ESTABLISHMENT: � � ' TEL. #�(�C��(��-
LOCATION AUDRESS: ` - . � -a�
MAILING E4DD S: ` � ' � s
OWNER NAME: - `" FE or rT • � '�
CORPORATION NAME IF APPLICABLE):
MANAGER'S NAME: TEL. # � _( ( , =I
MAILING ADDRESS:
_ _ _ . _ _ ___-- —_ _ __
POOL CERTIFICATIONS: --- - _
The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated
Paol Operator(s� and attach a cOpy of the certification to this form.__ . _
1. 2.
Pool operators must list a minunum of two employees currently certified in basic water safety, standard First A.id 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 maintafn a file at yonr place of business.
l. 2.
3. 4.
FOOD PROTECTION�vIANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 594.000.
Please attach copies of certification ta this application. The Health Department will nat use past years'records.
You mnst provide new copies and maintain a file at your establishment.
1. 2.
PERSON TN CHARGE:
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Each food establishment must have at least one Person In Charge (pIC)on site durin��iours of operation. -� - - '
1. 2.
HEIMLICH CERTIFICATIONS:
All foad service establishments with 25 seats or more must have at least one employee trained in the Hei.mlich
Maneuver on the premises at all times. Please list yow employees trained in anri-chokui�procedwres below and
attach copies of employee certifications to this form. The Health Dep�rtment will nat use past years' records.
You mast-provide new copies and maintain a file �t your place of business. :
l. - 2. _ _
3. � , 4. - : . : .: ..
RESTAURA,NT SEATING: TOTAL# �
4FFICE USE 4NLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE$ PERMIT# LICENSE REQUIRED FEE PERMIT#
_,BBcB $55 �CA$IN $55 _MOTEL $55
INN-� $55-_ �CA1yIP �55 �S��IGF�9L:..$�Qee. ___
_,_,,,LODGE $55 __,_TRAILBRPARK $105 ____WHIR.LPOOL $80ea. �
FOOD SERY�GE: ;
LICENSL REQUII2ED FEE PERMIT# LICENSE REQUIRED �'£E PERMIT# I,ICENSE REQUIRED FEE P�RMIT#
0-100 S�ATS $85 .�CONTINENTAL $35 NON-PROFIT $30
:>l00 SEATS $160 COMMON VIC. �60 WHOLESAL£ �80
RETAII.SERVICE: ____RESID.KITCHEN $80 �
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LIC�N$E R�QtJIItED. FEE PERMIT# _ . ,
LICENSE REQUIRED FEE P�RMIT# LIC�NSE REQUIRED_ FEE PERMIT#
<SO sq.8. $SO >25,000 sq.R. $225 VENDING-FOOD $25
„�<25,000 sq.ft. $$0 (,D+ON�� �FRQZEN DESSBRT $40 I TOBACCO $55 �10-6�
NAME C.HANGE: $is `AMOUNT DUE _ $ /35.o
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"**"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"«*
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ADNIINISTRATION
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Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's j
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATIOlw INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
i
_ CERT. OF INSURANCE ATTACHED _ _ _ __ _ _. _ __ . , . ;
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIt�TELY IF PAID:
YES N4
MOTELS AND OTHER LODGING ESTABLISSMENTS
TRANSlENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be !
limited to the temporary and short term occupancy, ordinaril�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. k
Transient occupancy shall generally refer to continuous occupancy of not more than thirCy (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 tha.t 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<Transie�rt.' ,
POOLS
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be u'�spected
by the Health Department prior to opening. Contact the Health Departmerrt ta schedule the inspection three(3)days
pnor to openiing.P�EASE NU'T�:People aze NOT allowed to sit m the pool area.until the pool has been inspected �
and opened.
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POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 paol must be drained or covered within seven(7)d�ys of
closin�.
FOOD SERVICE
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. _ . �
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FROZEN DESSERTS: _ : �
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Faailure to do so will result in the suspension or revocation of qour Frazen Dessert Pennit wrtit the I
above terms have been met.
OUTSIDE CAFES:
Dutside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. �
' 4UTDOOR COOKING: �
Outdoor cook�ng,preparation,or display of any fQod groduct by a r�t��food�erviee est�bli��arn�e�rtis prohibited. ,
NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN ,
THE COMPLETED RENEWAL APPLICATION(S)AND REQtTIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIV�ENT, MOTEL OR POOI. (i.e., PA►IIVTING, NEW �
� EQUIPMENT,ETC.),MUST BE REPORT'ED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
I TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
{ _ . ' , . :
DATE' ' C'oL � SIGNATURE:
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PRINT NAME&TITLE:
Richard Fournier
ov�asio9 Tax Manager
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_—=� The Cofnmo7zwealth ofMassaclzttset�s
" � Depm•t»ient oflndustrial Accide�zts
� — �ffice ollnvestigatinns
� 600 Washington Street, 7`h Floor
����J s Bostorz,Mass. 02II1
Workers'Com ensation Insurance Affidavit-General Businesses
name:
address: 100 CROSSING BOULEVARD
ci FRAMINGHAM state: M�' � ; 01702 (508)270-1400
hone#
work site]ocation full address :
❑ I am a sole proprietor and have no one Bnsiness Type: �Retail Q Restautant/Bar/Eating Establishment
working in any capacity. ❑Office�Sales(including Real Estate,Autos etc.)
�I am an em loyerwith 6,09�m loyees(full& art time). �Other
I am an employer pr iding workers'c pensation for�1�empioyees working on this job.
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❑ I am a sole proprietor and have hired the indegendent contractors listed below who have the following workers'
compensation polices: ;
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the impositioa of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civq penalt[es in the form of a STOP WORK ORDER and a fine of$100.00 a day againsi me. I understand that a
copy of this statement may be forwarded to the O�ce of v igations of the DIA ior coverage verification.
I dn hereby certify under ihe pai an e i of hat ihe information provided above is rrue and corr ct.
Signature � � � � � � _ �
Date _ '� '
Printname RI�HARD FOURPTIE
Phone# �508)270-1400
officfal use only do not write in this area to be completed by ciry or town officfal -
city or town:
permit/license# �Building Departmen[
� ❑check if immediate response is required �Licensing Board
❑Selectmen's Offire
_ contact person• phone#; ��ealth Department
' (revisedsep�zoo3) ❑Other '�.
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