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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 20I6. ' ��f,� Failure to do so will result in the return of your applicahon pac cet. _� ESTABLISHMENT NAME: n r�[. i LOCATIONADDRESS: UI.C� TEL.#: '??�-4 —� �g MAILING ADDRESS: 0 J S h15 ��! E-MAIL ADDRESS:_YY11�Ul'la.(� �1�,q�y1y►�,Q/�. tipyVl OWNERNAME:1'�I�I.VIA.G G(fi � I�d P.M In� wy-� �b(213o8�1 CORPORATION NAME(IF AP LICABLE : MANAGER'S NAME: Ed �UC�� . ( f+sV TEL#• MAII,ING ADDRESS: POOL CERTIFICATIONS: The poot 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. �, c �°�:; 1. 2, `--i tV �,°� " � t� .,�:?� Pool operators must list a minimum of two employees currently certified in standard First Aid and Community `� rv Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the �� ° empioyees below and attach copies of their certifications to this form.The Health Department wiil not use past � rn �� years'records. You must provide new copies and maintain a file a t your p lace o f business. a 1• 2. _ � 3. 4. ��..`�'�„F'�~ FOOD PROTECTION MANAGERS-CERTIFICATIONS: r:t:.�,,�� All food service establishments are required to have at least one fuil-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 IN CHARGE: a Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. "� 1. 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 Heatth Department will not use past years'records. You must � provide new copies and maintain a file at your establishment. 'T 1. 2. 6, 1 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-cholang 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 file at your place of business. � O 1. 2 _.. 3. 4 RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B S55 CABIN $55 _M07'EL $110 =1,ODGE SSS =TAA�LERPARK $$OS —SWIMMINGPOOLS110ea. _WHIRLPOOL S110ea FOOD SERVICE: L[CENSE REpT UIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# _>100 SEATSS $200 —CONTINENTAL $35 NON-PRO�IT $30 _COMMON VIC. $60 —'WHOLESALE $80 RETAILSERVICE: —RESID.KITCHEN S80 LICENSE REQ(JIRED FEE PERMIT# LICENSE REQUJRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq.8. a50 >25,000 sq.ft. 5285 VENDING-FOOD S25 =<25,OOOsq.ft. $150 � �FROZENDESSERT S40 3'TOBACCO $110 ��p�N�j�'Qg�� NAME CHANGE: $15 AMOUNT DUE _ $��_�--- AA� �� ••***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'*'* ��.�� a 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 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,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customxrily associated with motel and hotel use. i 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 OPErTING:All swimming,wading and whirlpools which have been closed for the season must be inspected s 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 i 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 Heaith Department three (3)days prior to opening and quarteriy � thereaRer. i POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing, FOOD SERVICE j SEASONAL FOOD SERVICE OPENING: ; All food service establishments must be inspected by the Health Department prior to opening. PIease 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 prior to the catered event. These forms can be obtained at the Health 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 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 ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTTNG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED$Y THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVAT'IONS MAY I IT LAN. DATE: >> W�6 SIGNATURE: � j� �—�-- �(� � PRINT NAME&TITLE:_ �� .�Q�(�USU/1 ��'��Q�j�/�r Rev.10/12/I6 � 1��'308y ,. : � The Commonwealth ofMassachusetts Depariment of Industrial Accidents Office of Investigations ' I Congress Street,Suite�00 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Business/Organization Naxne: Pafi%��1-�n ih 1s, �►1C• d,`b�� L!'¢�b(,p✓��J��. Address: ��J� ,S-��G� lg✓�(iVl.li(-Q� City/State/Zip: �0� �GUVYVWI�IV� 1�V�� phone#: �� 3� I e ou an employer?C6eck the appropriate boa: Business Type(required): �1.� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Resta.urantBar/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 corporadon and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have �p.0 Manufacturing no employees. [No woricers' 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 the'u workers'compensation policy infocmafion. � '*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensa6on policy is required and such an organization should check box#1. i I am an employer that is providing workers'compensation insurance for my employees Below ds the po[icy inforniation. ; Insurance Company Name: �� '�Q,�,{ � �,(/V�i�/�d�.� �J'�. ��/�p i � Insurer's Address: � � Z7/Z- ` . . ? City/State/Zip: �j��I(��'{,�l {�' �i{ �J � Polic #or Self-ins.Lic.# �-`��3�� ( 1 I��-- i Y Expiration Date: I Attach a copy of the workers'coarpensation policy declarahon 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 andlor 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby cert' u de t ains and penalties ojperjury that the informatdon provided above is true and correct. Si .a / e�S��n'�"'" �� ( t7 e S Dat Phone#: � ` � `'��q Official use only. Do not write in this area,to be completed by city or town offuial City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cierk 4.Licensing Board 5.Selectmen's Offce 6.Other Contact Person• Phone#• www.mass.gov/dia