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Home My WebLink AboutApplication and WC 1 – I i� , � d TOWN OF YARMOUTH BOARD OF HEALTH U�'��J �� APPLICATION FOR LICENSE/PE 0 B � �. � a FE 10 2012 � P _. � * Please complete form and attach all necessary doc � �` s,� eae�lte IS 2 ll _ � Failure to do so will Y•esult in the return of yo�ppl�`cation pac e �`��`"`�� i i � , ESTABLISHMENT NAME: � T • D �/ � / LOCATION ADDRESS: �Z� � TEL.#: �O - ' MAILING ADDRESS: S � i OWNER NAME: G'A��G'd/� �S�9NQ5 �i.'tl�UG`iL /"NL �Z2`�, �3�,�- � CORPORATION NAME(IF APPLICABLE): � �' �� MANAGER'S NAME: /�J/Cfr.�4�sZ. Ltn'' TEL.#: C�'3b2- 3Z� , MAII.ING ADDRESS: 2�� l.Jic.�.v�.,.� Sc'':� ��,�u?}t ,Qt' �Y1/1- t�ZG �.�' ' 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. , � 1 /1l/.� 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 j provide new copies and maintain a file at your place of business. I , � 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• /�� /K'�i�/ 2. � __ PERSOIV_I�__1_CHARGE_;_______�__ _ __ _ _. _ _ _ _ _ -- -- -- _ Each food establishment must have at least one Yerson In Charge(PIC) on site during hours of operation. � 1.��c�Fi¢0�0 ��L�N 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, 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 �MOTEL $55 _INN $55 I CAlb1P $55 �a"'� _SWI�IMINGPOOL $30ea _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 ( NON-PROFIT $30 �a"�Slp _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DFSSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ � S'rJ .O� *****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 INSURANC� � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I CERT. OF INSURANCE ATTACHED � G�R WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior�o renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � YES /Y��" NO � lVlor�EL�7 lil\1/ ollli�l\��il�ll'W��1�7111Y�1\l O TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy,ardinarily 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. � i , POOLS j POOL OPENING: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 openuig, and quarterly f thereafter. j �OOL 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 Yannouth 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, E 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. ! i , 6 OUTSIDE CAFES: # ��]�,�T� � �U�;i��:ui�"`u��i..-��tt�u'�i Z'rT�'%ttui�'GC'2ta�2:�ali:�i� u��S s�.`�i�"i:.�.��'.�.c ..j� i a _Yi�'r`��i�VYTT 41�1v LOcRI1TJl C71 f1E�iu��k.lt2� ( 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, 2011. ` A,LL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., Pf1I1�TTING, NEW � EQUI�'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF I-�ALTH PRIOR � TO COMMENCEME:NT. RENOVATIONS MAY FE E A S E PLAN. DATE: /�� 2d�/ SIGNATiJRF:� ` PRINT NAME�TITLE: �,�. �o S�/?� ��c��`�� F Rev.10/25/11 ' ! f r °' TO �VN OF YARMOUTH Boardof � Health 1146 ROUTE 28,SOUTH YARMOUTH, MASSACHUSETTS 02664-24451 H�� Telephone(508)398-2231,ext. 241 Division Fax(508)760-3472 APPLICATION FOR A LICENSE TO CUNDUCT A RECREATIONAL CAMP FOR CHII.DREN (Use back of application if additional space is neceasary) ��'; c«^^ Name of Camp:�Am� �/� „/��/�/� Site Address:_ 22� `//�/�>i/]E�,. Yf�►�Oc/%�,/e�/�/� �Z6�5� Site Address: Ta.x ID Number(FEIN or SSN): D��=2/� -/�/� . , �. ; .. Type of Camp: Day(less than 24 hrs.)� Reside�ial(24 hrs.) Hours of Operation: 9'�/VJ - �� U�' �� j /�//Z� Dates of Operation: Openin�: � �G!�-Y Z� J Z. Closing: /D ��'.!��Zt�/Z. / � Name of Camp Owner: , _�ij��,�'L,�Nl�S �1�� .l-��'�(G �z -� Qs�. ' �TT- Office Address:_Z ��i /LLr��J �iL�T Y��N/ f' _fl�,��,� Office Telephone Number: �U L-� - ��Z'�f �ZZ- Name of Camp Operator(if differern): Address: Telephone Number: Camp Director:_�yL��-��ir��n/ Address: Z 2�� 1 S�T �`��T��9"��/yl/� C�Z L�7'Z- Age:__�'�_ Telephone Number: .�;D13"-��/- ll/�� Cowsework in Camping Administration:��?�2�� r �,i� �5,�{-JU�� j�,�/�.J � Previous Camp Administration experience:Lf/n1I� //� � f(��1/ x�� -�C�� Healt6 Care Consultant: Type of Medical License: MA License number: Address: Telephone: ��$ 1 of 2 1 � � . i , ; Hospital for Emergency Services:�,��s �� SPi T./��... � � � - Health Snpervisor: .Qj�,9w'�� ,��l.Sl�/��'/� � Age:__�� Type of Medical License, Registration or Training:�iPG ,�/1/� /�S '� `��1 ,�T�S/�d/�CS� /ll'��f'/6 Swimming Area: Yes� No If Yes: Fresh Watsr �/ Qcean Pool CPO 74�- Specific Onsite Locations: L�Al1'I�r (/�!N�/J �/X�/� Water�haality Testing Performed By:�,Q.ly�'T��r.�.�,(/��C�� LRfSI��Ar!�/ '; Aquatics Diredor:_�c.CS A�t /1��"�� Submit Certifications: CPR�Q First Aid Water Safety--x� Other Lifieguards and Credentials:�c�il��1C'S �J �� ,� � Watercraft/Boating Activities: Yes� No Describe: ��j� �nroz S Food Service: /�{�}-y��q/�S Is food handles, served or prepared? Yes No� To what extent? Snacks Cooked and Served by Staff Tf cooked onsite,Food Manager(submit copy of ServSafe) Catered Tf so,by whom? Is refrigeration available for perishable foods? Yes Y No �,"_ Background C6ecks: Has the Camp Owner or Director obtained and reviewed the CORI and SORI of each sta.ffperson attd volumeer who may have conta.ct with a camper? Yes� No - - IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT 48 HOURS PRIOR TO OPEMNG TO SCHEDULE AN INSPECTION! THIS I5 MANDATORY! OVEItNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. SIGNED• PRINTED: ��/��f�j,/��—�/,��I�/ DATED: l� � See the neat page attuc6ed for � list of docnments that must be completed and submitted before your application can be fully pracessed, You are strongly encouraged to compiete these documents as saan as possibk and submit them in advaince. This will ezpedite the process. °�t� 2 of 2 . � NOTICE NOTICE TO � V� ? �O .�MPLOYEES � EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 . 617-727-4900 As required by 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 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC 6014316012011 03/31/2011 - 03/31/2012 POLICY NUMBER EFFECTIVE DATES Dowling&O'Neil insurance P O Box 1990 Agency inc Hyannis, MA 02601-1990 (508)775-1620 NAME OF INSURANCE AGENT ADDRESS � PHONE ^.ape Cod & islands Council inc ,oy Scouts of America 247 Willow St Yarmouthport, MA 02675 EMPLOYER ADDRESS � 03/31/2011 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE . MEDICAL TREATMENT The above named insurer is required in cases of personal injuries 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 First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonabie cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary -►d reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby no�ed that .�e insurer has arranged for such attention at the . NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER