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Home My WebLink About2016 Nov 03 - Returned RFS Applicationt . i �' TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 ` *Please complete form and attach a11 necessary documents by December 16 20i6. ; , Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME:_ TAX ID• LOCATION ADDRESS: TEL.#: MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME(IF APPLICABLE): �� MANAGER'S NAME: TEL.#: i, MAILING ADDRESS: POOL CERTIFICATIONS: I uThe pool supervisor must be certified as a Pool Operator,as required by Stnte law. Please list the designated Pool Operator(s)and attach a eopy of the certification to this form. /� 1 2 �' Pool operators must list a minimum of two employees currently certified in standard First Aid and Community �=� m 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 -r-� c.:� years'records. You mnst provide new copies and maintain a file at your place of business. z w rn � �a � � 1. 2. � -� fT'1 3. 4. -1 � � I 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 copiea and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2, ALLERGEN CERTIFICATIONS: All food service establislunents are required to have at least one full-time employee who has Aliergen certification, � as defined in the State Sanitary Code for Food Service Establishments,105 CNIR 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�le at your establishment. 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 a11 times. Please list your employees trained in anti-chokmg 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# ' LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H LICENSE REQUIRED FEE PERMIT# B&B C� a55 MOTEL SI10 I,ODGE $g9 _SWIMMING POOL S110ea. _TRAILERPARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �100SEA1S'S 5200 —��`�' a35 NON-PROFIT S30 — _COMMON VIC. Sb0 �VHOLESALE S80 RETA7L SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT il LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT l� I 1<50 sq.ft. S50 >25,000 ft. 5285 VENDING-FOOD $25 _<25,OOOsq.R a150 �ROZEN�ESSERT $40 =TOBACCO $110 i NAMECHANGE: SIS AMOUNTDUE _ � �p,�� , *"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••'• � r _ , 1 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 INSURANCE AFFIDAVIT 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: YES� NO MOTELS AND 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. 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 shali 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 POOL OPENING:All swimming,wading and whirlpools wluch have been closed for the season must be inspected i by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) ; days prior to opening.PLEASE NOT'E:People are NOT allowed to sit in the pool area until the pool has been j 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 Heaith Department three(3)days prior to opening,and quarterly � thereaRer. POOL CLOSING:Every outdoor in ground swimming poot must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPE1vING: 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 Yarmotrth 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.vazmouth.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 CAF�S: 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 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR PO ., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND D B THE B OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE I AN. ' � DATE:�' � SIGNATURE: � PRINT NAME&TITLE: P�t L Il C� Rev.]0/12/16 : . ' !� The Co»unonwealth of Massachuseits Department of Industrial Accidents Offue of Investigations ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Legiblv � f- D-- �A Business/Or anization Name: �'� � � �''�' � �L� � �S g db m � Address: �� (� i(V�(a�� S`t `(Z.� Z�� City/State/Zip: l/l�P�� VI rY1 til Phone#: � �1�4�.� S ��-?Z��- 3�'!4'� –�— Are y an employer?Check the appropriate boa: Business (required): l. I am a employer with employees(full and/ 5. etail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2•❑ I am a sole pmprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]* 4.❑ We are a non-profit organization,staffed by votunteers, 11.�Health Care 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 Wemselves,but the corporation has other employees,a workers'compensation policy is required and such aa organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees Below ds the policy information. InsuranceCompanyName: �-Q�(��C(� �,��t�P.,YLU��}�� Sf15, (� Insurer's Address: p.O. �b�C 1�S(� City/sta.te/zip: YV�� G�C.��tX� , �+A- a o�3LI y' ' I t-I �� Policy#or Self-ins.Lic.# �s(r��()I(� '�� (D3� �- d � /�i Expiration Date: �'�7 �7 Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration 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 Of�ice of Investigations of the D fo ' ce coverage verification. I do hereby c fy, e pains and penalttes ofpe�ur�th t the information provided above is true and correct. � '" Si a ; Date: /d 2.� � Phone#: � �I —()a �� Offuial use only. Do not write in thu area,to be completed by city or town official City or Town: PermitJLicense# Issuing Authority(circk one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#: www.mass.gov/dia