The URL can be used to link to this page

Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSElPERMIT-2017 *Please complete form and attach all necessary documents by,December I6 2016. Failure to do so will result in the return of your application pac�—' • ESTA$�.ISHII�NT NAME: ` � e rj LOCATION ADDRESS:�� (41ii.n s.1.k'1e .�y��m :. s�MA ��G�-.4 TEL#• 5 OH-�71('OI OO ' MAILINGADDRESS:�'t•2� � n C��{.E',�2��/'; -n o �1�1- C�� E-M A I L A D D R E S S: - �:��[,i d C�:M . OWNER NAIVIE: i h o��; t..r C � r rn i cllfii CORPORATION NAME�F APPLICABLE): rn I� G MANAGER'S NAME: ibl�al C0 . TEL.#: 3Q(,r MAILING ADDRESS: 22 � 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. Th�m�s Mc�_cC r rrn i�j 2. Pool operators must list a minimum of two employees currendy certified in standard First Aid and Community � � � Csrctioput�rtonary Resuscitation{CPR),having one certified emptoyee on premises at atl times. Please 2ist the �-- n �� employees below and attach copies of their certifications to this form.The Health Department will not use past �� O ;�;;•� • years'records. You must provide new copies and maintain a file at your place of business. j rn �n#� 1. 1��1 n_�"�pr_��.� Z.��.b��.�i� ✓i�r I�.� r�j �� F*r,€� 3. `� 4,,,_ -i rn mm� FOOD PROTECTION MANAC3ERS-CERTIFICATI�NS: 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 applicadon. The Heaith Department will not use past years'reeords. -� -� You must provide new copies aad mAintstin a file at your establishment. ��„' � -� 1. _�.�(i� ��: f1C� 2. ' PERSON IN GHARGE: � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � , 1. �h�� 5 Lu ��c.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 CN1R 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Depsrlmeat well aot nse past years'records. Yon muat pmvide new eopies aad maintain a file at your establishment. i. C h r� S �.�..�..� �c I� 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 ali times. Please list your employees trained in anti-cholang procedures below and attach copies of employee certifications to this form. T6e Health Department wiq not use past years'records. Yoa mnst provide new copies and maintain a file at yonr place of bnsYness. 1._�C�..eflt� �l.1,�11�1�.t,h 2.�%�C1�D('iC.10Q C�'�fjl.',Yl 3.�,,^�__5G� IC�%'e�,5� 4.�r�s l : r�el� � RESTAURANT SEATTNG: TOTAL# a2q � LUDGiNG: OFFICE USE ONLY LICENSE REQUIRED FBE PERMIT# LICENSE REQUIRED FEE PERMIT# y�CENSE REQUIRED FEE P RMIT# _�B $55 CABIN S55 ! MOTEL $110�� =L.ODGE a53 =—`!'RAI�LERPARK S$OS �WHIRLPOOLOOLS�1�10� �02,3 �OOB SERYICE: L CENSE REpU[RCD FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT N 0-100 SEA7'S 5125 CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS 5200 .�(0 3COMMON VIC. $60 �9 +yyF��OLBSALE S80 ��g�� =RESID.KITCHEN $80 L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRfiD FEE PERMIT# _<30 sq.ft. S50 >25 000 ft. $283 VENDING-FOOD $25 <25,OOOsq.ft $ISO _FRaZEN�ESSERT S40 =TOBACCO $1I0 NAMECHANGE: S15 AMOUNTDUE _ $ �00 .OD ****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*•"+ �0441,�.�y�-�—� ��'�"µP"O'103— C�� 1�✓o�SP-l4-6?c8-a3 a 3 (°>�o+KP-t�-o��-03 (wr�0o►►3P-��-o�c Z-o3 r t ADMINISTRATION Under Chapter 152,Secrion 25C,Subsec6on 6,the Town of Yarmouth is now reqnired to hold issuance or renewal of any license or permit to operate a business if a person or company dces not have a Certificate of Worker's Compensa6on Insurance. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT`SIGNED AND ATTACHED Town of Yannouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: � / YES �/ NO MOTELS AND OTI�R 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 sha11 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 collecrian of Room Occupancy Excise,as defined in M.G.L.a 64G or 830 CMR 64G,as amended,shall generally be considered Transien� POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departmentp or to open�ng. Contact the Health Deparlment to schednle the inspection three(3) days pt�ior to openiug.PLEASE NOTE:people are I+10"f'a(lowed to sit in the pooi area unh"1 the pool hss been ; inspected and opened. � POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standari plate count by s State certifieci�ab,�submitteci to ttze Healih Deparhx�ent ttu��{3)days�xior to opening,and quarterly therea.fter. POOL CLOSiNG:Every outdoor in ground swimming pool must be drained or covered within seven('n days of closing. FOUD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishmen#s must be insQected by the He�lth T�ne�tt prisr tu�g. Please contsct the Health Department to schedule the inspection three(3}days prior to openmg. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporazy Food Service AppIication form 72 hours prior to the catered event. These forms can be obtamed at the Health Degartment,or from the Town's website at www.varmouth.ma.us.under Health Department, Downloadable Forms. FROZEN DESSERTS: Fmzen desserts must be tested by a State certified tab 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 Fmzen Dessert Permit until the above terms have been met. OVTSIDE CAF�.`S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health ; OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPUNSIBILITY TO RETURN TI�COMPLETED RENEWAL APPLICAITON(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW j ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO CO I EMENT. RENOVATIONS MAY UIRE A ITE PLAN. : : DATE: �2. 6 � SIGNATURE: i�� 6rt � � PRINT NAME&TTTLE: +� C?�' Os�et,Q cC. Rev.IO/l2/l6 i ; � The Commonwealth of Marssachusetts Deprrrt�nent of Indr�strial Accidents Office of Investigations ' I Congress Stree�Srtite 100 Boston,ldlA 0,2114-2417. www.mass.gov/dia Workers' Compeasation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv BusinesslOrganization Name:�o�� C o c� �t c Sh U�l�0.a� Address:_�3�2 M[��n S��P� �o�t� QL8 City/State/Zip:S. Yw mv�?i-_,h , M� � O.�y Phone#: S(�8- �7 I - O 1(S C� Are yon an employer?Check the appropriate box: Busine.ss Type(required): l.[�I am a employer with empioyees(full and! 5. ❑Retail or part-time).* 6. [t�'�estaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � pffce andlor Sa1es(incl.real estate,auto,etc.) employees working for me in any ca.pacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of e�cemption per e. 152,§I(4j,and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]* 1 l.[]Health Care 4.❑ We are a non-profit organiza#ion,staffed by volunteers, with no emplayees. jNo workers'co�np.insurance r�.] 12.[]Other •Any applic�nt that chedcs box#I must also fill out the�cti�below showing their workers'compensation policy informaiion. '`*If the coiporate offieeis have e�cempted themselves,bat the eoipoiation has othes employas,a worlccrs'eompensation policy is rsquiceci and such an organization should chedc box#1. I am an empdoyer that is providieg workers'compensation inszeranre for my employee� Below is the pnlicy inforn�ation. Insurance Company Name: I')E'_I� CL P('0�2 C�"I p l(� t�1S�l('C�.►rl (Cs �O rr��l.,l Insurer's Address: � � ��3 �f G�,,�r� (Sp�C��1'2 City/State/Zip: U��'1 CC..i �,� �`�l�a�'1 PoIicy#or Self-ins.Lic.# '�-o2a C50� ��,�-1 Expira.tion Date: �� 3 J�.6�� Attach a copy of the workers'compensation policy declsration page(showing the policy number and egpiration date). Failure to secure coverage ss 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 civiI penalties in the form of a STOP WORK ORDER and a fine of up to$250.{�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. I do hereby ce fy,uRder tke pains and penalt�es of perjury tleat the inforrnation provided above is true and correc� Si d D 2- � (b Phone#: �• Offtcial use only. Do not write�n tkis area,to be co�npleted by city or town officia[ City or Town: Permit/License# Issain�Authority(circle one): 1.Board of Health 2.Bailding Deparlment 3.City/Town Cierk 4.L�nsiag Board 5.Selectmen's Office 6.Ot6er Contsct Person: Piione#: www.mass.govldia NOTICE �� NOTICE TO � TO EMPLOYEES ' ° EMPLOYEES ,� � . The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS C00 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) havc provided for payment to our injured employees under the above mentioned chapter by insuring with: Arbella 1'rotection Insurance Com an NAMI:OF I:VSL'1tANCF.COMPAtiY 1100 Crown Colony Drive, Quinc , MA 021 C9 AllDRrSS Oh'INSliRAiVCF,CO:VIPANY #4220051247 03/13/2016-03/13/2017 POLICY NUMBER EFFECTIVE DATES Hart Insurancc Agency Inc 243 i�Zain Street, l3uzfards Bay, MA 02532 1�AME OF IIv'SURAl�'CE AGENT ADDRESS MacLyn LLC & Irish Village Restaurant & Resort LLC 822 Route 28, S Yarmouth, MA 02664 EMPLOYER ADDRESS EMPLOYEK'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MI+IDICAL TREATMrNT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordancc with the provisions of the VVorker's Compensation Act.A copy of the First Report of Injury must be given to the injured employee. The employee may select his on c�r own physician. T'he reasonable cost of the scr- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and rcasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby noti�ed that the insurer has arranged for such attention at the Name of Hospital Address TO BE POSTED BY EMPLOYER