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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PERMIT-20i7 �rt � �Please compiete form and attach all necessary documents by December 16 2016. � � Failure to do so will result in the retum of your applicanon pac et. _ � ESTABLISHMENT NAME: � c 7� � `�� rn LOCATION ADDRESS: � 1 r" TEL.#: - 2�0 � ::: �''E MAILING ADDRESS: � " �I E-MAIL ADDRESS: L--b` � �L .C�I�vR OWNER NAME: �'tt_vt� CORPORATION NAME(IF APPLICABLE): �Li�t C'�i�-Y�.c IC�Lfi GP/�� ' MANAGER'S NAME:_�PS�i.2. 1'V�c rY�u.r��.e,� '1'EL.#: �� ..�� MAILING ADDRESS: _ <,ce..vv`2_ POOL CERTIFICATIONS: Z The ool su rvisor must be certified xs a Pool O � P pe perxtor,as required by State law. Please list the designated � Pool Operator(s}and attach a copy of the certification to this form. �.._____----- � ' 2• _._�.__..�-- �- .,�� . . V`� Pool operators must list a minimum of two employees currently certified in standard First Aid and Commanity �_:. (� Cardiopulmonary Resuscitation(CPR),having one cerl��iezi employ�on premises at all times. Please list the '� � [ emp2oyees below and attach copies of their c.erki�ations to this form.The Health Department will not use past � Q years'records. Yoe mnst provi�e.nerv'copia and maintain a filc at your place af business. (n 1. � 2. � 3. 4. ' O FOOD PROTECTION MANAGERS-CERTIFTCATIONS: � Ali food service establishments are required to have at least one fitll-time employee who is certified as a Food Protection Manager,as defined in the State Sanitazy Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certification ta this application. T6e Health Department will not use past years'records. � You m st provide new eopiea and mxintain a 81e at yonr estabiishmen� � �. ��c�cx-- �Jr��7�Y�.e.,r� z. ��2S�t..e, l�c d'�c�.�c��1 ...c PERSON IN CHARGE: � Each f establishment must have at least oae Peison In Charge(PIC)on site during haurs of operation. � 1. l lf�wl�.u�.. _ 2. ��.J PS� �1`1 C I/`1 U-�1� d ALLERGEN CERTIFICATIONS: AIl food service establishments are required to have at least one fWi-time employee who has Allergen certifieation, �, as defined in the State Sanitary Code for Food Serviee Establishments,105 CMR 590.009(G)(3}(a). Ptease attach m copies of certification to this application. The Healt6 Department will not use past years'records. You must � provide new copies and maintain a file at your establishment. � 1. �I�I��W�c:��,�� 2. � HEIMLICH CERTIFICATTONS: c All food service establishments with 25 seats or more must have at least one employee trai�d in the Heiunlich Maneuver on the premises at ail times. Please list your enployees trained in anti-choking procedures below and � attach copies of employ�certifications to this form. The Health Department will not ase past years'records. You m st prnvide new copies and maintain a file at yonr place of business. � t. �1 r.�.�.-�l � 2. l\.tJA'L_�i�l�V Y�.�--I 3. 4. � RESTAUR.ANT SEATING: TOTAL# � a...� OFFICE USE ONLY LODGING: LICENSE REQiJIRED FEE PERMIT# LFCENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# BBcB a55 CABIN SSS MOTEL S110 � SSS CAMP S55 _SWIMMING POOL SI IOea �.ODGE S55 �IRAll,ER PARK 5105 _WHIRLPOOL S110ea FOOD SERYICE: LICENSE REQ UIRED FEE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �Q-100SEATS 5125 ��Q(Z COMINENTAL S35 NON-PROFIT S30 >I00 SEATS 5200 �COMMON VIC. E60 � �Q =W►�OLESAI,E S80 RETAIL SERVICE: —RESID.KITCHEN SSO LtCENSE REQUIRED FEE PERMIT it LICENSE REQUIi2ED FF.E PERMIT# LICENSE REQUIRED FEE PERMIT# «sq ft. f50 . >25 000sq ft 5285 VENDING-FOOD S25 _45,00(Isq.ft. f150 _�RaZENDESSERT s40 TOBACCO SI10 NAME CHANGE: S15 AMOUNT DUE _ $ )�5.� ;"`*pLEASE TURN OVER AND COMPLETE OTHER S1DE OF FORM**"•" r ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any Iicense 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,Traz►sient 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 dweliing unit shall not be considered transient. Occupancy that is subject to t}ie 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 whiripoots which have been closed for the season must be inspected by the Health Departtnent prior to opening. Contact the Health Departrnent to schednle the inspechon three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until tlie pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total colifotm 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. EOOD 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 Yazmouth 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,�armouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthiy 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. OUTSID�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 nm annuaily 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 POOL (i.e., PAINTING, NEW F,QUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENC MENT. RENOVATIONS MAY RE U�tE A SITE PLAN. DATE: I t C� i� _SIGNATURE: .��, ' PRINT NAME&TITLE: I , �(..l}(�,Q�{�' Rev.10/17J16 � The Co�nmonwealth of Massachusetts Department of��dustrial Accidents Offire oflnvestigations ' 1 Cangress Street,Suite 100 Boston,MA 42�14-2017 www mass.govldia Workers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Le�iblv � �� Business/Organization Name: � � � I/�/ �G�.�it'i `� Address: (��!�-, ��}�- City/State/Zip:_yC�1'�U�� "`�Ph ne�� g —�Pa- �� Are yon an employer?Check the appropriate bozs Bnsiness Type(required): 1� I am a employer with�_employees(full and/ 5. ❑ Retail � or part-time).* b. �RestaurantlBaz/Eaxing Establishment 2.❑ I am a sole proprietor or partnership and ha.ve no �. � p��and/ar SaIes(incl.real estate,auto,etc.) employees�vrking for me in any capacity. [No workers' comp.insurance required] $• ❑Non-profit 3.❑ We are a corporation anc3 its officers have exercised 9. ❑ Entertainment their right of exemptian per c. 152, §1(4),and we have 10.Q Manufacturing no employees. [No workers' comp.insurance required]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no emgloyees. [No workers' comp.insurance req.] 12.[� Other *Any applicant that chedcs box#1 musi atso fill out the sectian below showing tbea workers'compensation policy information. *'If the corporate officcers have exempted themselves,but the corporation has oth�employees,a workers'compensation policy is required and such an organiration should check box#1. I am an emptoyer that is providin�workers.',compe��C i rance for my employees Below is the policy inforniatian. Inswance Company Name:_ 1 tv�. � Insurer's AddreSs: ��Q �'T��d J✓�C(� �'��,��/L� (�� 1�� City/State/Zip: Policy#or Self-ins.Lic.# �� r--.�j� Expiration Date: � � �� A#tach a copy of the workers'compensation poGcy decIaration page(showing the golicy number and eapiration date). Failure to secure coverage as required under Section ZSA of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$I,500.40 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK OFDER and a fine of up to$250.Q0 a day against the violator. Be advised that a capy of this statement rnay be forwardett to the Offics of Investigations of the DIA for insurance coverage verif[cation. I do hereby certi ,u der the puins and pe ' ofperjury that the informatiron provided above is true and correc� Si e: ' l��G /�o Date: Phone#: ;��"�J�---�()o�� . Official use anly. Do not write in this area,to be completed by c�ty or town officiaL City or Town: PermitlLicense# Issuing Authority(circte one): 1.Board of HeaIth 2.Building Degartmeat 3.City/Towa Cierk 4,Licensing Board 5.Selectmen's Uffice 6.Other Coatact Person• Phone#• www.mass.gov/dia 15 �p�,p��S_ wc o0 00 0o B� : ss � iNFORIlAAT10N PAGE �� WORKERS COMPENSATlON AND EMPLOYERS l[ABILITY POLiCY iNSURER- �T�� SII�� p� aF THg MIDWSST ONE HARTFORD PLAZA, HARTFORD, CONNBCTiC[3T 06155 NCCI Company Ntun6er. 20605 1 H� Comparry Code: G I�ARTFt)RD suffix LARS RENEWAL POLICY NUMBER: Os wsC Cr,s815 03 Previous Policy Number. oe wsc CL8815 HOIISING CQDSs DW 1. Named�stu+ed and IY�[ling Address: �ST�i'S �clTcxs�t, n�C. n� � (No.,Street,Tawn,State,Z�Code) T� o�rrtytis� cAr•s 134 ROIITS 6A FEIN Number: 383892174 YARMODTH PORT, MA 02675 State ldentification Nucnber(s): IIIN: �_ :�, ; The N81�'!@d IR8U1'�Bd!S: �RPORATION Bt�iness of Named Instx�ed: RSSTAURANT - FQLL sBRVICs (WAI Othe�workpiec��Sho�w�;�Oye: 134 ROUTE 6A YARMOUTH PORT MA 02675 2. POIiCy P@riOd: F�OIII 02/Ol/16 T0 02/41j17 1�d1 a.m.,Shandard tir�at the insured's ma��g addness_ Producer's Name� �� & Q'NEIL iNS AGENCY/PHS 301 WOODS PARK DRIVE Q�IN'lON, NY 7.3323 ProduCet'8 COd@: 088233 �Su�Rg OfflC@: THS HARTFORl} 302 WOODS PARIt DRIVE CLINTON NY 13323 (866) 467-8730 Total Estimated Annuai Premium: $1,199 Deposit Prernium: Policy Minimum Prerr►ium' $266 1►!A i�CLVDss INC�s�n LIMI� t+1�x. Px�rt.? Audit Period: �� Installmerrt Term: The pdicy is not bind'mg unless countersigned by our auttw%ed repressrrtative. Cou�ersigned by �'�no3� Ca�C`".vccc�a� 12/19/ls Authorized Representative Date Form WC OQ 00 Q1 A (1) Printed'm U.SA Page 1 (Continued on next page) Process Dabe: 12/19/15 PoUcy ExpFration Date: o2/oi/i�