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Home My WebLink AboutApplication and WC a �„ `� �� L,'�,�I�I� ri � � , � ► TOWN OF YARMOUTH BOARD OF HEALTH �MP ��NOU : JAN 17 2013 � APPLICATION FOR LICENSE/PERMIT-2013 ,_ �; ��O kp' � { � � * Please complete form and attach all necessary da�w��.��' . µ _ A TN ,��PT. ; Failure to do so will result in the return of��ur a�l�,�ti� . � I, ESTABLISHMENT NAME:��r�NDtll.� TAX ID• � LOCATION ADDRESS:�� i��ivtES��/i��19�vQT TEL.#:��_,3��28 MAILING ADDRESS: OWNER NAME: /��1'�r L�Df��" /�.M/fK L�dc�itJc/T/NG 2 2 �.S•� � CORPORATION NAME (IF APPLICABLE): �� MANAGER'S NAME: EZ TEL.#: - �Z- ZZ MAILING ADDRESS: d ` POOL CERTIFICATIONS: ' � I 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. ' 1 /Y 2.. _— _ Pool operators must list a minimum of two employees currently certified in basic water safety, st�ndard 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 fle at your place 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.OQ{�: 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�le at your establishment. � 1. 'o��p��-lm,na�` 2. � PER50N IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l.�.�--� ;� •. a � ��-tr�� 2. �r__-_ _ _____ _._____�,:___ ��_ -- __ _�_ __ _ ,,_ __ _ _ _ __ HEIMLICH CER'I'IFICATIONS: Alt 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. � 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 �CAMP $55 � —00�-I _SWIMMING POOL $80ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $80ea. FOOD SERVICE: __ �_- LICENSE REQUIRED FEE PERI�IIT# LICENSE RE U11tED FBE Y�Kri41T# iC:-L`�L;�E-- -j---— - Q ll i�r.1� ri;r, rL.,�� . ,, _0-100 SEATS $85 _CONTINENTAL $35 �NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICEN�E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.fl. $80 _FROZEN DESSERT $40 �TOBACCO $95 i NAME CHANGE: $i s AMOUNT DUE _ $ 8 S•00 ' i *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � � � ADMINISTRATION - � i a ; Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renev�al of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Co�pensation �Insuxance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFID�VIT M�TS�'BE COMPLETED AND SIGNE�;Ul�� `�• ' ` , � . � .-�, ;� �, ,• :� . . :' , �;,�, / . CERT. OF INSURANCE ATTACHE�" Y . , . ' . . �' . ' . ' � . OR `� � : '. - ' . ' ``` _ WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED � . . . , . �, . . � Town of Yarmouth taxes and liens must be paid pr",ioz to renewai`Qr.issuance of ypur p�rmits. PLEASE CHECK � APPROPRIATELY IF PAID: YES /1�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS _ _ ----, _ '_ • •� . f ..� - .,_. __ __ _ _ TRANSIENT OCCUPANCY: Fo'r purposes of the limitations of Motel or�-Iotel use,'�"ransient bccupar`icy sha11 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 j 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 f POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected i by the Health Department prior to opemng. Contact the Health De�artment to schedule the inspection three(3)days prior to opening.PLEASE NOTE:People are NOT allowed to srt 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. I 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 tl�e ', 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.varmouth.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 REQUIRED FEE(S) BY DECEMBER 15, 2012. 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 MAY REQUIRE ITE PLAN. DATE: Ui �/� SIGNATURE: PR1NT NAME& TITLE: / ��c�/�. ��..— Rev.10/09/12 :��' . °� r TOWN OF YARMQUTH Boardof � � xealth = 1146 ROUTE 28,SOUTH YARMOUTH,MASSACHLTSETTS 02664-24451 H�� a,..o Telephone(508)398-2231,ex� 1241 Division Fax(508)760-3472 APPL�CATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN (Use back of application if addifionaf space is necessary) �'°��"' Name of Camp: �i9/YI� /��I�lD�/�' - Site Address: 22� �NF �� 7�i�/l70t1��f Site Address: Tax ID Number(FEIN or SSN}:�' =. _ - - _ - . Type of Camp: Day(less than 24 hrs.}� Residential(24 hrs.} Hours of Operation: d�"fD l� ��D� Dates of Operation: Opening: b��GL�..�20/3 Closing: � ��ST 20� Name of Camp Owner:�p� ��rI1V05��AJN�/L /N,_.0��5•�► _ Office Address:_2� �/LLC.1�J��A7 a�O d rJ%T/� DZ��S Office Telephone Number: �OB'3��`�32Z— Name of Camp Operator(if dafferent): � Address: Telephone Number: Camp Director: n�S %� .�//17�•p Address: ' _ . Age: Telephone Number: � ' Coursework in Camping Administration: Previous Camp Administration experience: Health Care Consultant: � 8e ��T--e'r/!�� T of Medical License: MA License n�umber. p ype �. _. � Address: _ Tel one: � '•'"r"'E�. o5n��o 1 af 2 � ! � - y � Hospital for Emergency Services:�PG�C� i�f�'D�/TA'�-- Health Supervisor:�iQA w1 a�' C-�E/Sft��'E2 Age: Type of Medical License,Regisiration or Training: C� t SS � Swimming Area: Yes ✓ No If Yes: Fresh Water ✓ Ocean Pool CPO Specific Onsite Locations:�iP��N t�clGhl�N� Water Quality Testing Performed Byx��i1/STi� L�Ud�/y Aqua.tics Director: D�_��,/?�/n�D Submit Certifications: CPR First Aid Water Safety � Other Lifeguards�d Credentials: WateroraftlBoating Activities: Yes No Describe: Foad Service: I � Is food handle�served or prepared? Yes� No I To what extent? Snacks � Cooked and Served by Staff If cooked onsite,Food Manager(submit copy of ServSafe) Catered if so,by whom? I Is refrigeration available for perishable foods? Yes�� No ; ' Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each staff person and 1 volunteer who may have contact with a camper? Yes No Ill�ORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48_HOURS PRIOR _ : TO OPENiNG TO SCHEDULE AN INSPECTION! TffiS LS MANDATORY! UVEItriTIGHT ; CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUII.,DING AND FIRE � DEPARTMENTS. i � SIGNED: � PRINTED: /J/C/!a�l7A h�i�f'P,/1 DATED: / � See the neat page attached for a list of docnments that mnst be completed and submitte�i before � yoar agplication can be fnlly processed. You are strongly encouraged to comglete these docnments as soon as possible and snbmit them in adv�nce. ��s will eapedite the process. i � osna�o 2 of 2 , i A + � � NOTICE NOTICE TO . ;� ? TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTM�NT OF INDUSTRIAL ACCIDENTS ' 600 Washington Street, Boston, Massachusetts 02111 � 617-727-4900 � : As required liy Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned ; chapter by insuring with: ; � � � ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY � NAME OF INSURANCE COMPANY 54 THIflD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY ; VWC 6014316012012 03/31/2012 - 03/31/2013 POLICY NUMBER EFFECTIVE DATES Dowiing &O'Neil Insurance P O Box 1990 Agency Inc Hyannis, MA 02601-1990 (508) 775-162Q NAME OF INSURANCE AGENT ADDRESS PHONE Cape Cod& Isiands Council Inc � � 3o Scouts of America 247 Wiliow St Yarmouthport, MA 02675 �� EMPLOYER ADDRESS ` i � 03/12/2012 ' EMPLOYER'S WORKERS COMPENSATION OFFICER(II+'ANY) DATE � MEDICAL TREATMENT rhe above named insurer is required in cases of personal iqjuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the�rst Report of Ir�jury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related in,jury. In cases requiring hospital attention,employees are hereby notified that :e insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER