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Home My WebLink AboutApplication and WC f _ r � � ► TOWN OF YARMOUTH BOARD OF HEALTH 5 8 ��5� � o � � APPLICATION FOR LICENSE/PERNIIT -2Q1�� D � r��"'' ��x :.� . �°��` 81 �' ��!�� * Please complete form and attach all necess�doc��;'' ` er IS��Ol�. Failure to do so will result in the return tif ya�,`�l�ti" a et.HEALTM D�PT. ESTABLISHMENT NAME: ��S MCl�C ��'I LOCATION ADDRESS: ��J �c?��1 � 0 A��"nP� EL.#: �v MAILING ADDRESS: One CVS Dr. 23062A OWNER NAME: Woonsocket, RI 02895 CORPORATION NAME( {�PLICABLE): rmacy, nc. MANAGER'S NAME: � ` SS� ��+N TEL.#: ' o�� MAILING ADDRESS: `> � ,�.�v "� • ` r -- 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 copy of the certification to this form. L 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�le at your�lace of business. ' 1. 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. 2. PERSON IN CHARGE: 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 ' 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, i 3. 4• � _ RE�Ts9UK.�NT�EATING:_ TOTAL#�._..- - _ _-- ---__---____— - -- -- � OFFICE USE ONLY ; LODGING: � , LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _B&B $55 _CABIN $SS _MOTEL $55 _INN $55 _CAMP $55 _SWIMMWG POOL $80ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $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 f RETAII,SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMTI'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 VENDING-FOOD $25 _,{_Q5,000 sq.ft. $80 Z^�� _FROZEN DESSERT $40 �TOBACCO $95 �'� NAME CHANGE: $15 AMOUNT DUE _ � I—I r"J•O a f *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � �; � : 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 ESTABLISHIVIENTS 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 elsewhere.Transient occup�nGy shal_l �enerally refer to�ontinuous occupancy of not inore than thirt�(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. II POOLS '! POOL OPEI�IING: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 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 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 obtamed 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 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIl2ED FEE(S)BY DECEMBER 15, 201 l. 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. RENOVATIONS MA REQUIRE A SITE P N. � DATE: 1� ' �� SIGNATURE: � � j Jo nne P. Amitranm i PRINT NAME&TITLE: i Rev.10/25/11 t � � � ! ` ! The ��mn�onivealth afli�assacKusetts � � . i I3epartmenl nf�ndustriaT f3 cciaents �� 0.�'�ce n�In��esna ation� � 64(l Waslaington Street � � ~ I3ostor�,Nz� �y1�1 �' ww�tf.rrtass.govlaiu �vorl�ers' Compensation Insurance Affidavit: Generai B�usinesses Anp[ivant Tinfar�nation Please P�int�eQib�� . � . rr�_._ .. �...� hT rvc 1�. . . J_ �\"i� . ..: .. . . . . � . .. � . . . .. . .^.'�.�.5�YC�..!..:`L{..... ...... a.a 7% � ?��ddi�ss' l0� S�-�1�N �--- City/StaxeJZip: �� YM�3(� A Phone�: ,��o`�� I �s.re you an empio,yer?;Check>the appropriate bo�: � Bus�ness'£y{►e(reouiredJ: ( � c �t �e:ai� ( I.1�:� 1 am a empiover witn empiavees(fuii andi - � ` i ar part-time).* 6. ❑RestaurantBar/�rating Establislunent f 2,[� I am a soie proprietor or partnershig and have no 7_ (� p�ice ancUor Sales(inc1.real estate, auta;eL^,.; emniovees workiii�for me in anv cagacitc�. � [No workers' comn.insurance rec�uiredJ �. ❑ Non-profit � 3.❑ W e are a caiporazion and its officezs have exercised 9. ❑Enter�ainment ; their ri�ht of�xempuon per c. 1�2, §I(4),ant't we ftave 10,�Manufa;turin� � no emplovees. [No workers' comp.instuance required]* 11.0 Health Care ` 4.❑ �e are a nan-profit organizanan. stafEed by voiunteexs, � � w�ith no emplati ees. fi�io�vorKers' comp.inmirance req.} I ��.❑ �r ' *_�ny apnlican:thaf checics box#1 must also fitl ou[ti�e seetion beiow snowing their workeis'comoensation policY information. *xIf the corparaze officers have exempied themselvss,hat the cotporation has otiier emplovees,a workers compensation policy ss reguired and such an or�anizazion shouid chect�oot#L I am an emplover that isgroviaina warliers'comperzsufion insurunce for my emptovees. Beimv is thepoFi�p in�ormuiior Insuranc�Compa.��Nante: Ive�� tiamcshir� Insurance Comaan�� IIIStII'eT'S�iC�ZlTeSS: 1:'� Wa`A r S r r e e� Citvi St�t:,rZig: N�G' Y o r t:, Iv Y 10 0 3� Polic�T#or 5elf-ins. Li;.� 4309362 E�cpirationDate> 01 /01?201� �ttaeh:e copy of the�vvnl�ers'compensaLicsn noiicf�aeci�rafiaa p:�ge(sho�in�the poiicy number und eggirafion ciuc�}. �ail�r t��ec-�--�cvv�age as requu��una�r aecrian?�r�or ivitz�c. iS�can irad to th�imposition of c,;rn,n�i penalties of a ' fuie up to�L,SOU.00 ancl/or a�-vear imprisonment as weli as civil�nalties in th:,farm af a STOP WORIL ORI3�R and�fir� cf up to��50:0�a da��agair.st the violatQr. Be actvis:,cl that a copy of flis statement may be iorwarded to t'tae Office ox Invesagauons of the L?IA far insurance eoverage verificauan [aEo hereti ertify�,unc�er 1h ains penatties of perlurv tka�the infvrrrwtix�n providea abave zs arfce.an�eorrect � �� , _ - J2 I1.LrE: �3t� pho��e #: �Odn� P. F � C�fficiat itse ontv. I3o nvt write in tkis areG,ta be r.ornplete by citt�or un+nz n�rcial. i i � ( � �itv or Taw�c: Permit(I.icens�� , - Essuint Autbority(circle one;t; � ' L E`ward of f£eatth Z. Bui�din�33eoartuaeut s.Citv/Towr� �fer� �. I�ieensiga Board 5.Seieermeg's�fi��e �; 6. EJther i ' ! � f � �.D[ItBCC P�i'SO�: PElOite,i,+. ! � � www.mass:eovi di�