HomeMy WebLinkAboutApplication and WC `� � i
_ � � TOWN OF YARMOUTH BOARD OF HEALTH ��` �����
i� � � APPLICATION FOR LICENSE/PE -2 �
,.�. �,��� ,� �`,� FEB 14 2012
* Please complete form and attach all necess �c �a ts ` ber IS 2011.
Failure to do so will result in the retu " f y ` � 1 cation p c zet,v'��.� �'���'.
ESTABLISHMENT NAME: �S TAX ID: �
LOCATION ADDRESS: � TEL.#:'S -
MAILING ADDRESS:
OWNER NAME:
CORPORATION NAME(IF APPL ABLE):�p,X�U�►,�,��5 1��
MANAGER'S NAME: TEL.#: -�I —
MAILING ADDRESS: �'r
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Peal Jper�t�a�s) ����tta�r���op��f the��ti€°i�abx�is forin. _ _ .
1. C.1r;=
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2.
Pool operators must list a minimum of two emplo rrently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation . Please list these employees below and attach copies of
employee certifications to this form. The Healt artment will not use past years' records. You must
provide new copies and maintain a file at your ace of business.
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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. l.�A�� ��.�,a 2.
_ - P��or��v c�c�: _ _ _ _ _ _ _
Each food estabiishment must l�ave at l�as�-e��'erson�:�C�arge{PIC)-on site duxing hc�urs of operation. �
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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. I
You must provide new copies and maintain a�le at your place of business.
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1. 2. ,
3. 4, ',
RESTAURANT SEATING: TOTAL# `I� -!
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_IN1V $53 _CAR4P $55 _5 r`JIIvi1�+iIItiiG PCOL$8Jea
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea '
FOOD SERVICE: �
�
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIZED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
�0-100 SEATS $85 a�l� _CONTINENTAL $35 _NON-PROFIT $30 !
_>100 SEATS $160 �COMMON VIC. $60 ��Q�.7 _WHOLESALE $80 ;
I
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMTI'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i
<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 i
�<25,000 s ft. $80 �
9• �ra�,t,�J? _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $is AMOUNT DLTE _ � Z.ZS .C)O
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION .
lJnder 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
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AFFIBAVIT 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: j
YES NO '
;
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MOTELS AND OTHr:R LODGING�STABLISHMENTS
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 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 k
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 in 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.
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P£�OL CLOSIN�: Ev;,ry outdoor in groun�s;�%immin�pc��l mus�be�r�ined or ec�vered within seven(:i)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�armouth.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:
_�utside caf�s._(i.e.,�utdQor s�ating�ittz waiter/s�aatress sersrice)_must h.au�t�r angr4yal frr�mrhe Bc��rd af I�ealth._ _
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
j
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIlZED FEE(S)BY DECEMBER 15, 2011.
AT.T" RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED T�AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COlVIMENCEMENT. RENOVATIONS MAY UIRE A SITE P
1 DATE: � 'Ii SIGNATURE: '�"'�"
PRINT NAME&TITLE: dw��
� Rev.lO/25/11
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� � �� The Commonwealth ofMassachusetts
Departmeat of Indust�rial Accidents
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❑ I am a homeowner performing all work myself. ',
❑ I am a sole proprietor and have no one working in any capacity. '
[�I am an employer providing workers'compensation f�my employees worlcing on this job.
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❑ I am a sole proprietor,geaeral co�tractor,or�omeowner(cirde oiu)and have tured ihe contr�ctas listed below who`have
the following workecs'compensation polices:
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cepy•t thb�htr.me�may 6e forwarded b tlie Omce e[lave�as ot the DIA for eavense verfentlw.
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TNIS CERTIFlCATE IS ISSUED AS A MATTER OF INFQRMATION QNLY AI�CONFERS NO RIGHTS UPQN THE CERTIFlCATE HOLDER. THI$
CERTIFICATE DOES NOT AFFlRMATIVELY OR NEGATIVELY AIIi�NQ,EXTEND OR ALTER THE COYERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFlCATE OF INSURANGE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S).AUTHORIZED REPRESENTATIVE
OR PRODUCER,AND THE CER7IFICATE HOLDER.
IMPORTANT:If the cert'rficate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.H SUBROGATION Is WAIVED,subject to the
terms and canditlons qfi the policy, certain policies may require an endorsement A statemerrt on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PROIXICER
PAYCHEX INSURANCE AGENCY INC 5a:�a,»aez-s�as : �a�� en-oaa7
150 SAVVGRASS DR
RQCHESTER,NY 14620 �
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COVERAGES CERTIFICATE NUMBER: 063924635401540 REVISIQN NUMBER:
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INDICATED. NOTNATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH RESPECT Td WHICH THIS
CERTIFlCATE MAv BE ISSUED ORMAv PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN ISSUBJECTTOA�LTHETERMI,S,EXCLUSIONS
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CERTIFICATE HOLDER CANCELLATION
CARLUCCIOS LLG SFIOULD AN v OF T1�E ABOVE DESCRtBED POlJC1ES BE CANCELLED BEFORE THE
16 N MAIN ST EXPIRAiION DATE 7HEREOF N0110E WILL BE DELIVERED IN ACCORDANCE
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AUfHOWZED�SBdfATIVE
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ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
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