The URL can be used to link to this page

Home My WebLink AboutApplication and WC � ' ^' TOWN OF YARMOUTH BOARD OF HEALTH � �� APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by December 16 2016. � Failure to do so will result in the return of your appiication pac ecT�— ESTABLISHMENT NAME: ' /f. r ^ � , LOCATION ADDRESS: TEL.#: .s ' - O� MAILING ADDRESS: E-MAIL ADDRESS: !- OWNER NAME: CORPORATION NAM APPI.TCABL ): MANAGER'S NAME:�Q1jP_I�MI�� TEL.#: 5 ' c�� = O � MAILING ADDRESS: 5A rYil� m n m D -� � � POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated 2 �� t11 Pool Operator(s)and attach a copy of the certification to this form. p .Y e 1. 2. -�-I � v Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation(CFR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifica6ons to this form.The Health Department will not use past r-"•"'„' years'records. You must provide new copies and maintain a file at your place of business. - i 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 Establislunents, 105 CMR 590.000. ,� Please attach copies of certification to this application. The Health Department will not use past years'records. --. '� You must rovide new copies and maintain a file at your establishment. ' 1._��1 i�-�lG'C� 2. PERSON IN CHARGE: Each food establishm t ust have at least one Person In Charge(PIC)on site during hours of operarion. 1. �U S��`� �� 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 wil[aot use past years'records. You must prov� new copies a m intain a file at your establishment. 1. 1��a_L'1�� 2. HEIMLICH CERTIIFICATIONS: Ali 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 certificarions to this form. The Health Department will not use p$st yesrs'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� $55 CABIN $55 _MOT'EL Sll0 �.ODGE S55 C�p $55 _SWIMMING POOL$110ea _1RAILERPARK a105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# _0.100 SEA1'S 5125 _._,CONTINENTAL $35 �NON-PROFIT $30 �'��O _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. a50 >25,000sq ft. 5285 VENDING-FOOD $25 _QS,OOO sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: SIS AMOUNT DUE = S�Q.OO ****•PLEASE TURN OVER AND COMPLETE OTHER SIDE 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 COMPENSAT'ION 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 ttie limitations of Motel or Hotel use,Transient occupancy shall be limited to the'temporary and short tenn�iccupancy,ordinarily an�tcustomariry associate�with moiel aridhotel 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,sha11 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 aze 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 piate 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 Yannouth 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.yarmouth.ma.us under Health Department, D4wnic�adable�orms. 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 j OUTDOOR COOHING: 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 POOL (i.e., PAINTING, NEW ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � ' TO COMMENCEMENT. RENOVATIONS MAY RE A SITE PLAN. ' DATE: �b a� �� SIGNATURE� PRINT NAME&TITLE: �d b r st/ ��/V14�'h �C rC v r�"1��l��a//� Rev.IO/1L16 � � ; � The Cotnmonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Street,Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv Businessl0rganization N e: C!�( Address: � � � City/State/Zip:,p• ` j� M �k��lone#: ,��J!�'' �� Are y u an employer?Check the appropriate boa: Business Type(required): 1. I am a employer with '-� employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � O�ce and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• �on-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]* 11.0 Health Care 4.❑ We are a non-profit organizaiion,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.� Other 'Any applicant that checks box#1 must also fill out the secdon below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has ottter employees,a wodcers'compensation policy is required and such� organization should check box#1. I am an employer that is providin workers'compensaf n insu an�f'or my employees Below is the policy injormation. Insurance Company Name: Insurer's Address: 1 . ! �"1�C D i City/State/Zip: Policy#or Self-ins.Lic.# �(��lJ`.J�� Expiration Date: 1 7 � Attach a copy of the workers'compensation policy declaration page(showing the policy number and e�piration 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 DIA for insurance coverage verification. I do hereby certify,u he pains and pen Ities of per' ry that the information provided above is tru and correct. i a '' � Date: �� /� Phone#: ��.� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuin�Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cierk 4.Licensing Board 5.Selectmen's Office 6.Uther Contact Person: Phone#: www.mass.govldia NOTICE NOTICE TO �. TO ;� EMPLOYEES EMPLOYEES � , The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 . 617-727-4900 -http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: LM INSURANCE CORPORATION NAME OF INSURANCE COMPANY PO Box 9525,Manchester,NH 03108 (800) 562-3936 ADDRESS OF INSURANCE COMPANY WCS-31S-383187-026 O1-07-2016 Ol-Q7-2017 POLICY NUMBER EFFECTIVE DATES ROGERS &GR.AY INSURANCE 434 RTE 134 STE F1 50UTH DENTtIS, AGENCY INC MA 02660 (800) 553-1801 NAME OF INSURANCE AGENT ADDRESS PHONE# CULTURAL CENTER OF CAPE COD INC PO BOX 118 SOUTH YARMOUTH,MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF AN� DATE MEDICAL TREA'TMENT The above-narned insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonabie 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 tYie insurer, if the treatment is necessary and reasonably 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 NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYEIZ Insured CoDY