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Home My WebLink AboutApplication and WC TOWN OF YARMOUTA BOARD OF HEALTH APPLICATION FOR LICENSE/PERMTT-2017 *Please complete form and attach all necessary documents by DecEmber 16 2016. Failure to do so will result in the return of your applicahon pac et. i ESTABLISHILfEEIVT NAIv1E: 5 LOCATION ADDRESS: l( aR �Z'� a '�,#• ^��./(�pp) MAILING ADDRESS: E-MAIL ADDRESS: a. �o OWNER NAME: � v� CORPORATION NAME(IF APPLICABLE): 2 W��1 f}� Ibl '�" CO� MANAGER'S NAME: e TEL_#; � ': MAILINGADDRESS: /l4�i �c �Si. S .(��.�, UZLf��( il � POOL CERTIFICATIONS: The pool supervisor muat be certified as a Pool Operator,as required by State law. Piease list the designated ; Pool Operator(s}and attach a eopy of the certification to ttris form. � 1 2 � IPool operators must list a minimum of two employees currently certified in 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 nse past years'records. You must pmvide new rnpies and maintain a file at your place of basiness. 1• 2. _ � � 3. 4. � � Rl � -ri ;� ('j FOOD PROTECTION MANAGERS-CERTIFICATTONS: = w � All food service establishments are required to have at least one fiill-time employee who is certified as a Food � �� 'C Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CNIR 590.000. 'v `� R1 Please attach copies of certification to this application. The Health Department wilt not use past years'records. � � C3 You must pmvide new copies and maintain a file at your estab6shment. 1. 2, PERSON IN CHARGE: '�� Each food establishment must have at least one Person In Chatge(PIC)on site during hours of operation. 1. 2, ` � �= ALLERGEN CERTIFICATIONS: g�� All food service establishments are required to have at least one full-time employee who has Allergen certification, �` as defined in the State Sanitary Code for Food Service Estabiishments,105 CMR 590.009(G)(3)(a). Please attach �`� copies of cerkification to this application. The Heslth Department will not use past years'records. You mnst �� ma� provide new copies And maintain a file at your establisLment. ��.;r � 1. 2' l- HEIl�ILICH CERTIFICATIONS: —p � 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 � D attach copies of employee certifications to this form. The Heatth Department will not use past yesrs'recorda. Z � .� You must provide new copies and maiutaia a file at your place of 6usiness. � � 1. 2 �'1 3. �. O �� ,.. RESTAURANT SEATING: TOTAL# "O Z LODGING: (�. OFFICE USE ONLY � � � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT# � � � �� S55 �� $SS M01EL 5110 ��Y C� m CAMP S55 �SWIMMING POOL$1(Oea �•�� f55 TRAILERPARK $105 �WHIRLPOOL Sl10ea j FOOD SERVICE: (/ ICENSE REQ U[REp FEE P LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� 0-100 SEA'1'S 5125 E��-� CONTINENTAL $35 NON-PROFIT S30 � >too s�a1s szoo Zco�,nv�or�v��. � �? �o�s�,E sso RETAIL SERVICE: —RESID.KITCHEN SSO LICENSE REQUIREp FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERhIIT# =a��1•ft• ft S50 >25,000sq ft 5285 VENDIIVG-FOOD S25 00(!sq. S I50 =FROZEN DESSERT L10 _TOBACCO S 110 NAME CHANGE: aIS AMOUNT DITE _ $ (p 2S•�O *•'**PLEASE TURiV OVER AND COMPLETE OTHER SmE 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 COMPENSA'1TON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVI'I'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 Mote]or Hotei use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotei use. Transient occupants must have and be abte 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)ilays,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. � POOLS � � POOL OPENING:All swimming,wading and whirlpools which have bcen closed for the season must be inspected by the Health Department prior to opening. Contact the Health Deparlment to schednle the inspection three(3} clays prior to opening.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 Iab,and submitted to the Health Department three(3)days prior to opening,and quarterly ' thereafter. POOL CLOSING:Every outdoor in ground swimming pooi must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Atl food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Depaitment 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 obtau�ed at the Health Department,or from the Town's website at wvwv.varmouth.ma.us under Health Depatiment, 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 Fmzen Dessert Permit until the above tern�s have been met OUTSIDE CAT'�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. j OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is proLibited. i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII,iTY TO RETURN ' TI-IE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i ? ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAIlVTING, NEW i ; EQUIPMENT',ETC.),MUST BE REPORTED TO AND APPROVED BY BOARD OF HEALTH PRIOR I TO COMMENCEMENT. RENOVATIONS MAY A STI'E A . , DATE: I�'�Z I G SIGNATURE: � i PRINT NAME&TITLE: ��O v C��„ �t��i r� " r�_ , ►��.ia�vte � The Com�onwealth of Massarhusetts Department of Industrial Accidents Offue of Investigations ' 1 Congress Stree�Suite 100 Boston,MA OZll4-2017. www mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaalicant Information Please Print L�blv Business/Organization Name: �2u'�Pd�l �� a'� /Vt�.,�CC7R-� ' Address: � �-� E'_ 02 City/StatelZip: �r Ck��C9�- � ��Phone#: �l� �" ��t�-( ('o Q C�� Are you an employer?Chec the appropriate boz: Bnsiness T�pe(r�.nired): 1.�--I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantlBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � p��a/or Sates(incl.reat estate,auto,etc.} employees working for me in any capacity. [No workers' comp.insurance r�uired] 8. ❑Non-profit i 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exempfion per c. 152,§1(4),and we have 1 p 0��ng � no employees. [No workers'comp.insurance requiral]* 11.0 Hea1th Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other i 'Any applic�nt thffi checks box#1 must aI�fill out the sectian betow showing their worke�s'campensation policy infoimation. i "If the corporate offioers have exempted themselves,but�e corprnation has other employxs,a wodcars'compensation policy is required ffid s�h an organization should chedc box#1. I am an employer that is providixg wor s'compensation rance f my employee� Below is the policy information. Insurance Company Name: �� LTa�I.`�-�c)�C,� Insurer's Address: ��e- ��"�-��rc� ��c�Z�. � �� . � City/State/Zip: Gc/li V Q(� � �-� Policy#or Self-ins.Lic.# �� 1=.C� �� Expiration Date:� 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 andfor one-year imprisonment,as well as civil penalties in the form af 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 forwazded to�e Office of Invesfigations of the DIA for insurance coverage verification. I do herehy certify,u the pains and ' of e jury that the iriformation provided above is true and correc� Si �— _ Date: �' j • 1'O Phone#: �D g '3�,� �, d c� j Ojficlirl use only. Do not write in this area,to be co�npleted by city or town official City or Town• Permit/License# Issning Antharity(circle one): 1.Board of HealtL 2.Bnilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia