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Home My WebLink About Application and WC ' _ �D TOWN OF YARMOUTA BOARD OF HEALTH ' AP'PLICATION FOR LICENSE �'� �' �' � �01� � * Please complete form and attach ail neces ' ber ��,T ' Failure to do so will result in the re �et:�--�"��=�_----- ; ' ESTABLISHMENT NAME: r - i : LOCATION ADDRESS:_.S�i �dUr� �!'1 TEL.#: CS�� 'G�2��-�- i MAILING ADDRESS: If D '" /N � � ' E-MAILADDRESS: ��t�1�S � Y�C,.o�. [�tv! � OWNER NAME:��1� ��Ps�77�c•r CORPORATION NAME{IF APPLICABLE): i� _ �: ! MANAGER'S NAME: ��5 Ctfe�i c�t.i TEL.#: SD� G��'-O'3��- � MAILING ADDRESS: S,� ��1u7'F �R �'AP.�/B�r,p'j l� t�i?L�T p''�I� ��-� POOL CERTIFICATIONS: The pool supervisor must be certified As n Paal Operator,as required by State law. Please list the designated Pool Operator(s}and attach a eopy of e certification to this farm. 1. /v' 2. Pool operators must list a m' ' of twa employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitafiion (CPR), having one certified emp loyee on premises at all times. Please list the ' employees below and attach copies of their certifications to this farm.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. ; FQOD 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 Hcalth Department will not use past years'reeords. You must provide new copies and maintain a file at your establishment. ; �. ��-1��1 2. Wl t�� Ll!'�� ± ,, cH��s�n:t�� c��-=��.,� �� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site dwring hours of operation. 1.�..L....�-�� -� I�'l�� 2. ��'1�� (�'/�C-�-(.��C�� ALLERGEN CERTIl�ICATIONS: � All food service establishments are required to have at least one full-time employee who has Allergen certification, i as defined in the State Sanitary Code for Food Service Establisliments, 105 CMR 590.009(G)(3xa). Please attach ! copies of certification to tlus application. The Health Department will not use past years'records. You mast provide new copies and maintain a file at your establis6ment. I._IA?�'tCrsJV��. �111�1�L 1�C"�S , 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich MMaxneuver 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 wili not use past years'records. You must provide new copi�s and maintain a fite at your place of business. 1_f��'G�`L _T5 f,H��TGq(�I 2. ��i��L�i�J�� I��7�t��ut 3. tu ��-��.�.�f�l�l��I_�,�� 4. A4�2��Fv Nlr,�t�.e4�'L'!�', RESTAURANT SEATTNG: TOTAL# �I r.oncnvc: OFFICE U5E ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $SS CABIN S55 MOTEL 5114 � SSS CAA�Il' S55 =SWIMMING POOL S110ea. I.ODGE S55 TRAILERPARK 5105 _WHIRLPOOL SilOea FOOD SERVICE: LICENSE REpUIRED FEE ��2� LICENSE REQUIRED FEE PERMIT# LICENSE RE�UIRED FEE PERMIT# �0-140 SEA�'S 5125 CONTINENTAL S35 NON-PRO Tf S30 >l�SEATS $200 �COMMON VIC. Sb0 �Q —"WI;OLESALE �80 RETAIL 3ERVICE: —RESID.K.TI'CHBN S80 LiCENSE REQUIRED FEE PEI2MIT# LICENSE REQ[7iRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 8. S50 >25,000 ft $285 VENDING-FOOD S25 '=<25,�sq.ft. $150 � �ROZEN�ESSEItT S4d TOBACCO $I 10 NAME CHANGE: $1S AMOUNT DUE _ $ ($ _—��•, _ . *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*;+i* \ t��-�.�Z�-c,3 � � � � The Co�»monwealth ofMossachuseds Departnunt of Indusd�ial Accidents Offtce of Investigotions ' 1 �ongress Stree�Suite 100 Boston,MA 02I14-2017. www.�ss gov/dia Workers' Compensation Insur�nce A�iidavit: General Businesses A licant Information Please Print 'bl Business/Organization Name:�� -, L� 1� I��'k'r�tTN ' � �' Address: ��'-1 '(c.�?(� �F� City/State/Zip:�i4Qi � �1" Phone#: �,��)��-� ��-� Are y �n employer9 Check the a propriate boz: Business Type(reqnired): 1. I am a employer with �`—/� employees(full and/ 5. ❑R �l or part-time).* 6. RestaurantrBarr/Eating Establishment 2.❑ I am a sole proprietor or parhiieiship and have no �, �p��or Sales(incl.real estate,auto,etc.) employees working for me i.n any capacity. [No warkers' comp.insurance required] 8. ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainment i their right of exemption per c. 152,§I(4),and we have Z O.Q Manufa�cturing no employees. [No workers'comp.insurance required]* 4.❑ We are a non-profit organi7ation,staffed by volunteers, 1 L[]Health Care with no employees.[No workers' comp.insurance req.] 12.[�Other `�Y aPPlic�t Wat c�Cks box#1 must also fill o�rt the sectian below showing their workeis'co�en�iun Policy informati�. s sIf We coiporate officers have exas►ptied themselvas,but the corporation has otha emPloYees,a worlcers'oompensation Polic,7'is requi�ed�d such an otganization should check box#1. I am an employer that ts pmvWing workers'coinpensatlon�irirance for my emp[oyee� Betow is the po[�cy injormatiorr. InsuranceCompanyName: IOiO� [�-�tf��D .T11�"�iAQ.I�I��t"� CEJtMP�JUIC" Insurer'sAddress: �(}. I�dX �—N�J�c�,. �"C1/�� T1Z��T �_ 'T � , Ci /State/Zi �L tY P: 1�. i�LI��S-- R� �G � �R�-��--��.� Policy#or Self-ins.Lic.# �� t�� Expiration Date: �� Attach a copy of the workers'compensation policy declaration page(showing the policy nnmber and eap rstion da#e� Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of eriminal penalties of a fine up to$1,540.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.Oi?a dsy against the violator. Be advis$d that a copy of this statement may be forwarded ta the Office of Invesdgatians of the DIA for insurance coverage veTification. I do hereby ce ' the and o rJury that the inforn�ation provided abo �s hue d correc� Si ��rc z� :�-� ,,1�� /,�- D �— y �hone#: C�Q$ �'�f�`—�°`��" ��`� OfflcFal use oRly. Do not write in tkis ar�a,to be compteted by cJty or town o,�''iciwL City or Town• PermitJLicense# Issaing Anthority(circle one): 1.Board of Hea1tL 2.Bailding Department 3.Citq/Town Cl�k 4.Licensing Board g,Seiectmen's Oifice 6.Other Contact Person• Phone#: www.mags.gov/dia . , , � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut 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 ATTAC�IED l/ ! � . Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: 1 / . YES V 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 etsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty(30)days,and � an aggregate of not more than nuiety{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 tlie collection of Room Occupancy Excise,as defined in M.G.L. c.64G or 830 CMR 64G,as amended,sha1l generally be considered Transient. ( POOLS � POOL OPENING:All swimming,wading and whirlpools wluch have been closed for the season must be inspected by the Heaith Deparbment prior to opening. Contact the Health Department to schedate 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 mspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total colifarm and standard plate count ; by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. ' POUL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL F4UD 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 Towa of Yarmouth must no#ify the Yarmouth Health Department by filing the reqmred Temporary Food Service Application form 72 hours prior to the catered event. These forn�s can be obtained at the He la th Deparlment,or fram 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 monthly thereafter,with sample results submitted to the Heatth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut untii 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. OUTDOOR GOOKING: Qutdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Perinits 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 ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINfiNG, NEW ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BO OF TH PRIOR � TO COMMENCE NT. RENOVATIONS MAY RE SITE . DATE: � � SIGNATURE: ��u� � � �, � .� PRINT NAME&TITLE: �,,�-�� -L C�G TZ- �'��f��'l•`7— ; � xev.la�2/16 � �