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Home My WebLink AboutApplication and WC � : _ � �..� . � TOWN OF YARMOUTH BOARD OF HEALTH �� ' � � APPLICATION FOR LICENSE/PE I -� r, �� 0 5 �013 ..o�- ' �;. * Please complete form and attach all� � � e�a;�s y ce 13. Failure to do so will result in the .�e�n c��q�ax�a�r;p��afi ` s.',:�'•'. ��:.,a �.<. :aw- ,. k.. •�� " �� ESTABLISHMENT NAME: ov T I : ' LOCATION ADDRESS: TEL.#: o�- - yd MAILING ADDRESS: �!�I7 t�rllvw Sd� �larr►�v� Por�� M./� oa to7.S' E-MAIL ADDRESS: 0.m . Zc��n � sc ou�� .o�' OWNER NAME: � i 1 � CORPORATION N E (IF APPLICABLE): s�.me as ce.tiay� � i MANAGER'S NAME: ;�h �I j e TEL.#: — - d• i MAILING ADDRESS: N �!lo � /�o �.� i I 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. �� 2. __ Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and � Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. ' i i L 2. i 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee wha 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. YYI L:-�-�i Y1 2. —� PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � _ - 1. __ �rn�� Z,o�.�✓in 2. ; ALLERGEN CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who ha.s Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. �rnv Z.a�nn 2. • ; ; HEIMLICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich i Maneuver on the premises at a11 times. Please list your employees trained in anti-chokuig procedures below and attach i 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# ' i ________ __�__ � _ _ _4 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 –C� SWIMMING POOL $80ea LODGE $55 TRAILER PARK $105 WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _0-100 SEATS $85 _CONTINENTAL $35 1 NON-PROFIT $30 I�F 0 � >100 SEATS $160 _COMMON VIG $60 WHOLESALE $80 , —RESID.KITCHEN $80 RETAIL SERVICE: ! LICENSE 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.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ cd�.0� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � __ .�� _.�.� _� I � ..•��_: � .. . , . ;� � ADMINISTRATION Under,Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance t�rene��al of any license or perniit 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 1NSURANCE 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 AloTD OTHER LODGING ESTABLISHMENTS _ 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. j Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. � Transient occupancy sha11 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. ` E POOLS 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 Department to schedule the inspection three (3) days prior to openmg.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. ( � POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. _ __ _---___ ——-—�_ _ - _ _ _ riuf)� �E�Vii:E __ _ _ --- ____._._ _---- _--- 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 Departrnent 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.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: I 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 RESP�NSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I' EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO '' COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL N. i DA�TE: /I SIGNATURE: I PRINT NAME&TITLE: Q - t �Y►c,� Rev. 10/08/13 � � I � _ . ��Q�r7in�C� �Fie� D�`l�: °� ' TOWNOFYARMOUTH Boardof � � � �, Health = 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 - ''*�� Telephone(508)398-2231,ext. 1241 Health Fax(508) 760-3472 Division APPLICATION FOR A LICENSE TO CONDUCT A RECREATIONAL CAMP FOR CHILDREN (iJse back of application if additional space is necessary) . . Name of Camp:_��p�o� �� Site Address: o�o�r] (�"i nQ, S�" l�('yy��d('-� Site Address: T��Number(FEIN or SSN): .(`�� Type of Camp: Day(less than 24 hrs.) � Residential(24 hrs.) Hours of Operation:___ j�-� �c�.wt ' ,�,�,�c Dates of Operation: Opening: Closing: Name of Camp Owner: �'�n ('�,r-�, °"�S�py1�5 �'�.��i i �7�oV �co��3 o7�ru�ef'lcc� � � Office Address: o�y 7 LI/��f��il S�l�i.r I/�2(�U� 1�D('-� D�,1� �.� Office Telephone Number: .�� _'��a' �-/�,�a� Name of Camp Operator(if different): Address: Telephone Number: Camp Director• ��n, u��Q �e.i S�n�C,�(�P�i" Address:_ �9S �o�1cn �r'�c��- �� E• Fa.�►naJ'�� !� 0dJ�3 �o Age: LJrI Telephone Number: �O�- ,5 yl� - L/19(p Coursework in Camping Administration: (,u� S ca c��' �v ('��/��,a�n�S�a�/on Previous Camp Administration experience:�eaf3 a,a owtl� (�I(e��f Health Care Consultant: J�,t �-� SS� /1�j� Type of Medical License: ��,`�� /��iG��'!� MA License number: 1�a 7(o a Address:_ /3Q /�Ov'� S7 /7'y�h%S Telephone: 3'O�r- 9S',�(o_3�U o5no��o 1 of 2 � � � • - , { Hospital for Emergency Services: �ccpe � ��SA►� � i � , • Health Supervisor: �,��{'�/ ��rp�q� , { Age: LI / Type of Medical License,Registration or Training: Cpl�� i,sf,�id, Cav�� (�c D�j�- Ttarni»ct �! Swimming Area: Yes No If Yes: Fresh Water � Ocean Pool CPO Specific Onsite Locations: �QSIq�r1a.'�CC�. Sw►mv+a�✓i4 oi.!'e.�a. m f Gr�,woval� f�r� Water Quality Testing Performed By: �t�'n S}�p�� -��-(,�, Aquatics Director: �B �/r'! ��G��V Submit Certifications: CPR � First Aid � Water Safety Other Lifeguards and�redentials: _ . WatercraftlBoating Activities: Yes � No Describe:_(�ppahG ` kc�/41Cinq J Food Service: Is food handles, served or prepared? Yes ✓� No To what extent? Snacks� Cooked and Served by Staff If cooked onsite,Food Manager(submit copy of ServSafe) . Catered if so, by whom? 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 volunteer who may have contact with a camper? Yes ✓ No IlVIPORTANT! CONTACT 'i'HE YARMOUTH HEALTH DEFARTit'IENT 48 HOURS PRIOR TO OPENING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERI�TIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUII.DING AND FIRE DEPARTMENTS. SIGNED: PRINTED: DATED: I / See the next page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the process. osnono 2 of 2 � , NOTICE � � NOTICE x TO � � TO a ,� � � EMPLOYEES p�� $�� 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 payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutuai Insurance Company NAME OF IN5URANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 . . ADDRESS OF INSURANCE COMPANY VWC-100-6014316-2013A 03/31/2013.-03/31/2014 POLICY NUMBER � EFFECTIVE DATES P O Box 1990 Dowling&O'Neil Insurance Hyannis, MA 02601-1990 (508)775-1620 NAME OF INSURANCE AGENT ADDRESS PHONE Cape Cod & Islands Council Inc Boy 227 Pine St Yarrr�outhport, MA 02675 EMPLOYER ADDRESS 03/21/2013 � 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 reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonabIy connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY EMPLOYER ADDRESS TO BE POSTED BY EMPLOYER