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Home My WebLink AboutApplication and WC ,,,. °��;�L'u'sU ITOWN OF YARMOUTH BOARD OF HEALTH (�� `� � ��'�S I �� APPLICATION FOR LICENSE/PERMIT-2017 i *Please complete form and attach all necessary documents by December 16 16. y�,c�L-j-� p�r�-1- � Failure to do so will result in the return of your applicanon pac et. ESTABLISHMENT NAME: � nS TAX ID• 04' Z'�16'72�1 � LOCATIONADDRESS: 1�`-1 'P..�ra cs:wt��. � �'"��' �v`�P1'EL.#: Sa?-"iG0-,f'/S"1 MAILING ADDRESS: �! �;��:, S'� 'A' �'Z� �� .M�'t� �2)0� E-MAIL ADDRESS: „ ,�' a OWNER NAME: CORPORATION NAME(IF APPLICABL .p�;�ra k. Y_p h►��v ci.,► rr v, fi�o�n Car�� MANAGER'S NAME: M.Y-'� Av��YSO✓1 TEL.#: !"a'�'-?Cov- S'/9) MAILING ADDRESS: µ�v,dcr� � ��ic r��,y��n c-�c� i POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) d attach a copy of the certificarion to this form. _ �. C� �i'� 2. � � �� Pool operators must list a minimum of two employees currently certified in standard First Aid and Community I�'," �-� (�� Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the ;r"• �' (x, I employees below and attach copies of their certificadons to this form.The Hea1tL Department will not use past � ' years'records. You must provide new copies and maintain a�le at your place of business, f� �� 1. �1 � Y T 2 �� 'r �i 3. 4. `�_ ;.�a; � � :I ( FOOD PROTECTION MANAGERS-CERTIFTCATIONS: All food service establishments are required to have at least one full-rime 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 Healt6 Department will not use past years'records. `� i You must provide new copies and maintaia a file at your establishment. 1. ��R1F � l�►�1_1 �'t'n �f� 1� 2. T� , ��:. ,; PERSONIN CHARGE: �`'b �� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ��u l. 'SACAi�S L t L 1.t iarM S�i L 2. � ��1Y f»-;) ALLERGEN CER'TIFICATIONS: ��. `�� -�,� 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 mast provide new copies and maintain a file at your establishment. 1._�AcnrS `�) 1LLi AthSo�� 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 fde at your place of business. 1. � Mf;.." r �-L ��ti�Sv � 2. �AW rLi,i 1Pti � 3.�� ..i., i7 Cc3 /lt 4. � RESTAURANT SEATING: TOTAL# Loncmc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� S55 CABIN a55 _M07'EL $110 =LODGE $SS C'`�� S45 _SWIMMING POOL Sl l0ea TRAILERPARK S10S _WHIRLPOOL SllOea FOOD SERVICE• LI aN0 S�Q [�p SE� PERMIT# LICCONTINENTAL D $35 PERMIT tl LtICNON-P O�N�D s30 P I��i3 _>100 SEATS 5200 _COMMON VIC. E60 �A+HOLESALE S80 � — RETAIL SERVICE: —1tESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT t� L[CENSE REQUIRED FEE PERMIT# _<50sq ft. S50 >25,000sq ft. 5285 VENDING-FOOD S25 _Q5,000 sq.ft. S150 =FROZEN DESSERT$40 =TOBACCO $110 NAME CHANGE: S15 AMOUNT DUE _ � ;�{j,fjQ ••*'*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•;*+' , ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth 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 Compensarion 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 ANb 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 limitadons of Motel or Hotel use,Transient occupancy shail 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)iiays,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. 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 un61 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: Atl food service establishments must be inspected by the Heatth Department prior to opening. Please contact the ! Health Department to schedule the inspecdon three(3)days prior to opening. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Hea1th Departtnent by filing the reqwred Tempo Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the H�th Department,or from the Town's website at www.varmouth.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 wilt result in the suspension or revocarion 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 ha�e prior approval from the Board of Health. j OUTDOOR COOKING: i Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ; ' ALL RENOVAITONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ; ; EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THEBOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �)- /�- /� SIGNATURE: �� 6��- � � , PRINT NAME&TITLE: �f 1CG�� ,�jc.'7I' �v- rgY��•.'-��]- Rev.l0/l2/l6 � The Commonwea[th of Massachusetts Department of Industria[Accidents O�ce of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv Business/Organization Name: �10��- � �= � �. ��t�-�c�� .h.� c�P,e�n s � r ,oN ��;t.�� , Address: \ ?��}. �i vc� ��,�C� � o�-�. �.��t City/Sta.te/Zip: ��.ti�`��,,,�,�,�,,,�,,, �� Phone#: � �� - 7 C� p- s � � I Are you an employer?Check the appropriate boa: Business Type(required): 1.[.� I am a employer with�employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantlBar/Eating Esta.blishment 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] 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 volunteers, 11.[]Health Care with no employees. [No workers' comp.insurance req.] 12.[]Other •Any applicant that chedcs box#1 must also fill out the section below showing thea workers'compensation policy informatiar. **If the corporate og'icers have exempted themselves,but the corporation has ot6er employees,a workers'compensation policy is required and such an organization shouid chedc box#1. I am an employer that is providi �vo kers' ompensation Insurance for y employee� Below is the po/%y information. Insurance Company Name: Insurer's Address: � � City/State/Zip: '�k�-5��, M,� C>�11(� Policy#or Self-ins.Lic.# ��a1-.�jS�3'��1`dL�9� u 2 4 Expiration Date: "�- � ' 1�1 Attach a c�opy of the workers'compensatiau 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 da.y against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verifica.tion. I do hereby cernfy,under the pains and penalties ofperJury that the information provdded above is true and correc� _... . / / r/ s�enaz�u��_,;=�i�'��Y�__ I� G _ � Date• - ,/�-l Phone#: � Cl - '7 C�(> --�) �-� Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Aathority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cterk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia