HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOA��C�' RECE{VED
�
� � APPLICATION FOR LICENS�/P'� � -� '� _fi� �' OCT 21 20 i 6
�'"� * P l e a s e c o m l e t e f o r m a n d a tt a c h a l l n e c e s s d o u m e nt��F D e, m b e r 1 6 2 0 1 6.
Failure to do so will result in the return of your application T
ESTABLISHMENT NAME: TAX ID: � 3Z
LOCATION ADDRESS: 6 u`� 2 S� A2 nou 6f o TEL.#: o - o
, MAILING ADDRESS: SnrVtF_ A S � o uf
' E-MAILADDRESS: V�-H i IU P�2(?,�A L1nn � �r,�1
OWNER NAME: �
CORPORATION NAME ( F APPLICABLE): �NT-E � �.S �G
MANAGER'S NAME: �£S � A ��� TEL.#: c5 - - I
MAILING ADDRESS: �r��� '�,�zlL`� Z� S� ��A R. /1d tT11r( f`1Pr D,2 s��,
.
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 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.
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. 2.
PERSON 1N CHARGE:
Ezch fcad establish�-nent must have at ieast one Person In Charge (PIC) on site during hours of operation.
l. 2.
ALLERGEN CERTIFICATIONS:
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 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.
l. 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 fle at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFF�CE USE ONLY
LODGING:
LICENSE REQUIR�D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$I l0ea.
_LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 .-OI'� CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 / COMMON VIC. $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. $285 VENDING-FOOD $25
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ I8 S�OO
**''�**PLEASE TURN OVER ANI)COMPLETE OTHER SIDE OF FORM**x**
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ADMINISTRATION ;
I
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 1NSURANCE ATTACHED ;
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es 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 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 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 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 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.
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 Yarmouth Health Department by filing the '
required Temporary Food Service Application form 72 hours priar 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:
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 ESTABLISHME T, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND ROVED BY THE BOARD OF HEALTH PRIOR
,
TO COMMENCEM NT. RENOVATIONS MAY RE �A SITE PLAN.
,
�C� 2.( ; �I . �(�,
DATE: � SIGNATURE: � (�/t;
. ` � �
PRINT NAME & TITLE: I/ j /�- W N fi
Rev. 10/12/16
� The Commonwealth of Massachusetts
Department of Industrial Accidents ;
_ Office vf Investigations '
' y 1 Congress Street, Suite 1 DO ,
Boston, MA 02114-2017 '
www.mass.gov/dia '
.
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv '
Business/Organization Name: �U� (1, � tS�S l� �7 ' U G��o�(J t� ���
Address:
City/State/Zip: Phone #:
Are y an employer? Check the appropriate boz: Business Type(required):
1. I am a employer with�employees(full and/ 5. ❑ R il
or part-time).* 6. Restaurant%Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• ❑ 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 warkers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
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 themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an emp[oyer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: (' �G�D � I � ' C� - ��� �
Insurer's Address: �j �I �UT� Z� w�� ������(�U� � �;� C5�(U ��
City/State/Zip:
Policy#or Self-ins.Lic.#��� �O Z .5 7 �I� Expiration Date: C �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration 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 Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert der the pains and pena[ties of perjury that the information provided above ds true and correct.
Si ature: li�" ` Date: O —2 C5 �
Phone#: D�� ' �
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
t
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other '
Contact Person: Phone#:
wwwmass.gov/dia