HomeMy WebLinkAboutApplication and WC �
�L�-€:-k,������j�p���- �, ��U�i�ul�l�CD
• TOWN OF YARMOUTH BOARD OF HEALTH
" APPLICATION FOR LIC;ENSE/P'ERM1T-� �� JUN 191013
'�Ptease complete facm a�attach all n�cessary documents by HEALTH DEPT.
Fail�e to do so will resvlt in the return of your applicaaan p .
ESTABIdSHIt�N'r NAME: ""��' ^ �
LOCATiON ADDRESS. !-d e ••� ,.�o,n�,o �A, �,.,*-- 5�ft�G�3—C`�c�
�
MAII ING ADDRESS: SQWt .
OWNER NAME: �i 2d I s.uAr Q ,
�
CORPORATTON NAME(IF APPLtCABI_E):
�.vvAc��s xaME: ��: p 2 3 Z013
MAII ING ADDRFSS:
rooLCat'r�cwTto s: H AITH DEPT
Tlu pool �be cxrtified�a Pa�Opecator,ffi cecluired by stste law.Please tist the
Pool and attach a cogy a�ihe c�tificaaon to this facm. �� ` �
.�- a m �$�
1. 2, �a: � `` ,
�:.u� a�;
�''
Poal operata�ss must list a minimwn of two emplo cmrenfly are�d in basic water safecy,standatd Fiist Aid
�
and Co CpEdiopu tmonarY Resuscitatian !R). Please list�se empioyees below a�l att�h copies of
. emplooyym����ations to this fonn.Tbe H�ith Degartment w�7t�wt n�ae past Y�rs'reoor�s. You most
provide�copres and msiateTm$fite at your pisoe��.
lr,.�.�'' 2.
3 4.
FOOD PRO'rECTtON MANAGF•RS-CEItTIFtCATIONS:
All food�rvice establisi�nnents are reqaired tio have at le�t a�ne full-time emPloY�ae who is ce�tified as a Food
Protedion Manage�>as defined in the State Sanitary Code fo�'Foad Sexvice Establishments,105 GMR 59QA00.
Please attach copies of oextification to tlns application.The Heaith DePartment w�not nse pastyears'recwids•
Yon mast provi�new c�op�and maintain a 61e at yoar estaWisb�meat.
1, �1 ��rl�M�i_l�l�� —2. ---
PER50N IN CHARGE:
Each food establi�nt mn�have at kast o�Pexson In Char�e(PIG7 on site dnrit�g hours of opesa4ion.
�,F�,�.,� A�tr�caw�ara 2.
�H CQtTIl7ICAZIONS:
All food servicx establisbments w' seats ar more mnst have at least one e�loyee tranned in the Heimiich
Manenve,r on d�e premises . Please list youremployees trained in anti-chokmg pmcedures below and
attach copies of empd . . to tbis fiarm. The Healf� wID not use p�t yes�rs'reoords.
Y�mnet oopi�and m�a 6ie at yonr pl�oe b�.
1
3. 4.
RESTAURANT SEATING: 1'OTAL# `�U i
OFFICE U5E ONLY
[.oncnvc:
uc�atss�um� � r�trm'# uc�rtssx�Qum� � �r# vtc�t+t�x�u� z� r�xau�rr
�&g Sg5 CASIN S55 _MOTFL SSS
�NN S55 GAMP SSS _SWA4f1NC3POOL SBOea
_JADC�E S55 TRAIIffit PARK 5105 _�- 3�•
FOO�S6BVICE:
LIC9�i3B R�[lII�Pffi PIDtMiP� IJ(�NSE REQ[IIItED F86 EBR1vIIT 1' IIf�iSB RBQLIII� FE6 �1'i
ai��,Ts sas _coNTn�rrrai, s3s �r�t-r�ea�rr sso
�ioo se,�zs Sieo co�oat vtc. s6o wt��sn� s�
e�r�n.�vic�: �xEsro.xi�rc�sao ���
�c�sa�u�n r� �ma�r t uc�arsE�u� � r�rrr �ssxa�u� r� e�r*
_c90�ya. sw ��spoo�q.a. s2�s �v�nnaci-t�sxs
_asAoo�.a. sa� _FRo�D�.s�c'S4o _rnsna� �S9�5'
x�c�xc,E: sis AMOUNT DUE _ $ u��' .
,�••r�.e,�ss iven ovEa erm coa►�r�oTeeR smE oF�««•
/� s r
a
� ApMIIVISTRATION
Under(�apter 152,Section 25C,Snbsecti�6,the Town of Yarmowh is now r+equired to hold issuance or renewat
of aay licease�peimit to op�ate a basi�ass if a parson ar c�mpany does not have a Certificate of Worker's
Com�on Ins�oe. THE ATTACHF� STATE WORKER'S COMPENSATION INS[IRANCE
AFFIDAViT MUST BE COMP�.ETID AND SIGNED,�R
C�RT.OF INSURANC:�ATTACHED •
o�
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Tawn of Yarmouth taxes and liens must be paid prior to renewal or issuance of your peamits. PLEASE CHECK
APPRQPRIATEI.Y IF PAID:
y� ✓ NO
MOTELS AND tYl'HE8 LODGING F�TABLISffi1+IENTS
TRANSIENT OCCUPANCY: For pmposes of the limitations of Motel or Hotel use,Transient aaupancy shall be
limited to the temporaiy and short tenn occupancY>ordinarily and customanly associated with motel and houel use.
. Transient occupants must have and be able to demonsccate that fhey maintain a principat plare of residence
e14ew1�.TYansiern ocxupancy shall�nerally rafer to continuous occupancy of not mare tham thicty(30)days,and
an ag8regate of not mo�e than ninety(90)days within any six(�month period.Use of a gnest unit as aresidence or
dwelling nnit shall nat be consid�ed tiansient. Occupancy that is snbject to the colleaion of Room Occapancy
Excise,as de�ed in M.G.L.a 64G or 830 Cd►�IIt 64C3,as amended,shaIl generaliy be considered'Pransient.
� ��
POOL(3PEIVING:All swimming,wading and which have been clased f�the season must be'
by tbe Heaitb �nt or Wopemag.Contact���Health De�M W schednle the inspacti�tl�e�
a�nd op��, � " :Paople are NOT allowed to sit m d�e pool area until die pool has be�n inspected
POOL WATL�R TESTING: The watet must be tested for pseudomonas,total colifrnm and standazi plate count
by a State certified lab,and sabmittc�to the Health Department three(3)days prior to opening,and qaazte�ly
thaeafter.
POOL CI.OSING:Every outdoor in gtou�d swimmmg pool mast be draiaed nr coveced witiun seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food seavice establish�cnts mnst be ins�by the Healdi Depaxoment prior to opening. Please c�►tact the
Health Depa�ent to schedule the inspearan three(3)days priar to oPening•
CATERING POLICY:
Amyone who catcxs within the Town o�Yacmouth mast notify the Y�mc�th Hzalth Dep�ment by filing the
r�u�r�T good Service Applicauon form 72 honrs pri�to t�catered event. �ese f�s can be
obtazn�d at the�He th Departmern,o�from the Town's website at www.vstmouth.maais under Health Depactrnent.
Downloadable Foims.
FROZEN DESSERTS:
Frozen desserts must be tested by a State ceatified lah gricu to opming and manthly�,with sam�le reeotts
su6mitted to the Health Department. Eaihue to do so w�l resalt in the suspension or rev�cation of yonr Frozen
Desaert Pamit�mtil the above terms have been a�t.
4UTSIDE CAF�S:
Outside cafes(i.e.,ontdnor seating with wsit�/waiuess s�+ice)>�st have pr�or approvai firnnthe Boazd of Health.
OUTDOOR COOHING:
Outdoa c,00kiag,px�Cstion,a display of any food producx by a retail a�food savice e�ablislunent is proWbited.
NOTICE:Peamits raa annually frnmJanuary i bo Decembet 31.IT IS YOUR RF.SPON5IBII.ITY TORETiJI2N
TI�COMpIETED RE[�1EEWAL APPLICATION(S)AND REQtJIRED FEE(S)BY DfiC�1ViBER 15,2011.
ALL RFNOVATIONS TO ANY FOOD ESTABLiSHIvIF.NT, MOTEL OR POOL(i�e.,PAIIVTING, NEW
EQUII'MENT,ET'C.),MUST BE REPORTED TU AND APPitOVED BY THE BOARD OF HEAL'TH P'RIOR
TO COMNff��iC�1T. RFNOVATIOIdS MAY LTIRE S .
DATE:���D ,'� SIGNA � �►----
PRIIVT NAME 8c TT12,E:
x�.�arzsn�
, � The Commonwealth of Massachusetts
Department of Industrial Accidents
�` Office of lnvestigations __ .__.___ ___-- -.__
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
AAnlicant Information Please Print Legiblv
Business/Organization Name: ��Z.GQ�-ryl. M�YV QY�1.Q��
Address: � � (�
3
City/State/Zip: GI 1�'�'YtOLI �/j Phone#: 54�—(, ;�
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
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. ❑ Entertainxnent
their right of exemption per a 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,staffed 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'compensation policy is required and such an
organizafion should check box#L
I am an employer that is providing workers'compensalion insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers'compensation 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$250.00�a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, de he pains andpenalties ofperjury that the information provided above is true and correct
Si ature: Date:
Phone#: �CJ �'
Official use on[y. Do not write in this area,to be completed by city or town officiaL
City or Town:_yA-�,�rc�. Permit/License#
(circle one):
1.Board of Health .Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6. er
Contact Person: Phone#: �D$-3QQ-��3� k 12Y1
www.mass.gov/dia