HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTA
APPLICATION FOR i,iCENSEIPERMIT-?Ai7
"Please compiete form and attach all necessary documents by L1��� rr�r 16,2a16.
Failure to do so will result in the return of your application�a et
ESTABLISHMENT NAME: �- � =01 - f r
LOCA"i"ION ADDRESS: / R-f� � /�M(�J TEL.#: °-�7' D� 8 E�.
MAII.ING ADDRESS: D
E-MAIL ADDRESS: f o C�? Q O . �Dr✓t ,
OWNER NAME; n 0 .
CORPORATION NAME APPLI ABLE • ra v� _ �
MANAGER'S NAME: ��ZYVI Ue I `d � ' TEL.#: - 6 O � � � m
MAILING ADDRESS: M - �1! ' _ �; �
m
POOL CERTIFICATIONS: � �
The pool supervitor must be certi5ed as a Pooi Operator,as reqairad by State Iaw. Please list tbe designatsci � � �
P�i{3perator(s)and attach a copy of the certification to this form. �
�
4. 2. _�
Pool operators must list a minimum of two employees cumenfly certified in standard First Aid and Commimity
Cardiopulmonary Resascitation{CPR},having one cemfiedea�ployee on 'ses at atl timcs. Pleaa�e tist t�
employces below and aitach copies of their c�rtific�s to this forn�.'�e��t�net�se paat - ..-_a....#
yea�a'r�or+tis. Yoa mnat provide new copies Aed muintnin s file at your glace of basines�.
�
i. 2. -'
3. 4. � p
FOOD PRCITECTION IvIANAGERS-CER'I�ICATIONS: �
A!1 food service estabiishments are required w have ai least one full-time employ�wlm is certified as a Food � ,.
Prc�t�tion Menager,as defined in the State Sanitary Code far Food Service Establishments, 14S CMR 590.OU0. � :
Pleas�e attach copies of certification to this appiication. The Aealth I�partment will not nse psst years'records.
Yon mast previde new eopies aad maiataia a file at your e�stablis6�eo�
I._ �,QY►'►l.l(!.l �'`� ' 2.
PERSON W CHARGE:
Each food establis�ment must have at least one Person In Chazge(PIC)on site during haurs of operation,
L �C��'v��.f �! l��o z, $
�
Ai•T"RRGEN CERTIFICATIONS: 1
All food service establishmenis are required to have at least one fiill-time employee who has Allergen certificatian, N
as defined in the State Sanitary Code for Food Service Esiablishments,105 CMR 590.009{G�3xa). Plea�e attach �
copies of c�ertification to this appiication. The H�lt6 Deparimeot w�7t not use past years'reeords. You mast �
provide n�v copies aad maintain a 6ie at yonr eatablis�men� b
�. t�1��, 2l�q�h- 2. N
HEIMLICH CERTTFiCATTONS:
All food se�vice establisitmeats with 25 se�s a�more m�t have at Ieast one empic�ee tr�nod in i#�e�iah
Maneuver on the premises at all times. Please list yo�s employees t�ained in anii-choking procerlures below ar�d
attach copies of employee certifications to this form. The Healt6 Departmeat will not use p�st years'records.
You must provide new copia and main#ain a 61e at yonr piace of bnsine.ss.
1. 2,
3. 4.
RESTAURANT SEATTNG: TOTAL# ��•
OFFICE iTSE ONLY
iADGIIYG:
i.iCETTSfi itEQUIRED F£E PERMIT 0 LICENSE REQUIRED FEE PERMI'f# LICENSE REQUiRED FEE PERMiT�t
&@B SSS CABtN S55 MOTEL SllO
tNN SSS CAMP S35 =SY✓A�IMMINGPOOLSIlOea.
�.OIXiE S55 =$RAII.HRPARK 5105 _Wf[IRLPOOL SIIOea
POOD 3ER�YQ[C6;
�.L WESE+1's�� Si2s ��3I L'�coSxcw�Errr� �S PERMIT� LI NCENON�-PRO �� � PERMiTk
>ioo ssnTs szoo �co�ox v�c. �o �p —wHor.Esn� s�o
�rnn s�vics:
—�sro.xrrcx� sao
LiCENSE REQUIRED FF.E pE1fMp�# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT 11
<50 saft. SSQ . >25,OOUsq�R 5285 VENDiNG-FOOD S25
=Qi,ObO sqR 5150 _.FROZEN DESSERT S40 �1'aHACCO SI 10
AMOUNT DUE -� �T
NAMECHANG�: �SIS —s,
+.� i i _..,
****•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 peimit to operate a business if a person or company dces not have a Certificate of Workea's
Compensation Insucance. THE ATTACAED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED_��
OR
WORKER'S COMP.AFFIDAVIT StGNED AND ATTACHED�
Town of Yarmontk taues and liens must be paid prior to renewal or issuance af your permits. PLEASE CHECK
APPItOPRIATELY IF PAID:
YES_� NO
MOTELS AND OTHER LODGINC ESTABLISHMENTS
TRANSIENi'OCCUPANCY: For purposes of the limita#ions of Motei or Hotel use,Transiern occ�cy shall be
}imited to the temporary and short term occupancy,ordinarily and customarily associated with motel and ho'tcl use.
T�sient ooa�pants must have and bc able to demo�ate that they msintain a principat Pl�e of residence
elsewhere_Transi�i occupancy shalf genecally refer to continuous occupancy of not more than thirty{30}days,and
an aggregate ofnot mor�than ninety(9U)days within any six{6)manti�period. Use of a guest unit as a r�idence or
dwelling unit shall not be considered h�ansient Occupancy that is subject to tlie collection af Room Occupancy
Fxcise,as defined in M.G.L.c.64(i or 830 CMR 64G,as amended,shall generally be cansidered Transient
POOLS
POOL OPENING:All swimming,wading and whiripools which have baen closed for the season must be i�acted
by the Health Dep�tment prior toopea�ng Cont�t the He�ithDepa�ent to se6ednM the ia4pethon thrce{3)
drys prior to openimg PLEASE N�TE:People are NOT allowed to sit in the pool area imtil t�e pool has been
inspected aad opened.
POOL WATER TESTING: The water must be tested for pseudomonas,totat coliform and standari plate count
by a State certified lab,aud submitted to the Health D�rtment tht�e(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 mnst be inspected by the Health Deparqnent prior to openieg. PIease contact the
Health llepartmeni to scheduie the inspection three{3)days prior to opening.
CATERING POLICY:
Anyo�who caters within the Town of Yarmouth must notify the Yarmouth Healih Department by fili�g the
breq�T���Food Service Application form 72 hours prior to the catered event. These forms can be
Dowmlo�dable F���'or from the Town's wetrsite at www,yarmouih.ma.us under Health Dep�hn�
FRfJZEN UES.SERTS: -
Fmzen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health Department. Faiiure Yo do so wi](resulY in the suspension or revocation of your Fr�zen
Dessert Permit wrtil the above terms have bcen met
OUTSIDE CAF�S:
Outside cafes{i.e.,outdoor seating with waiter/waitress service),must have prior approval fram the Board of Hesl#h.
OUTDOOR CQOIQNG:
Outdoor c,00king,�eparation,or display of any food product by a retail or food service establishment is prnlubited.
NOTTCE:Permits nm annually from January 1#o December 31. IT IS YOUR RFSPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATIflN(S)AND REQUIRED FEE�S)B�DECEMBER 16,2016.
ALL RENOVA110NS TO ANY FOOD ESTABLISHMENT, MOTEL OR POL3L (i.e., PAINfING, NEW
EQUIPMENI',ETC.),MUST BE REPORTED TO AND APPR VED BY THE BOARD OF HEALTH PRlOR
TO COMMENCEMENT. RENOVA'iTONS MAY REQ SITE PLAN.
DAT'E: C O f� �{o - SIGNATURE: 4
PRINT NAME 8c T1TLE: �v �• �-�c.� �
x�.o�iz��a
� The Commortwealth of Massrrchuseus
Dcpartnunt of Ind�rstrial Accidents
O,f�`'ice of Investigations
= 1 Cor�gress Stree�Sirite 1+�0
Boston,MA 421Y�2017.
www�rtus�gov/dio
Workers' Campensation Insarance Affidavit: General Businesses
AuD�c.ant Information Ple�se Print Leeiblv
Business/Organization Name: ��K - �- �O l..1-.
Address: r� � , �� �� , � � �a�'✓�-t e u�"�
City/StatelZip: W l-l4 0����' Phone#: .�o - 76� -�'�� '
Are yoa an employer?Cbeck t6e approgriate boz: Basiness Type(reqnired):
1.�1 am a employer wi#h�employees(full and! 5. ❑Retaii
or part-time).'� 6. �RestauranfilBazlEating Fstablishment
2.❑ I am a sole proprietor or patinership and have no 7. ❑p����or Sales(incl.reai estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a cor�ration and its officers have exercised 9. ❑Ent�tainment
t#ieir right of ex�mption per c. 152,§1(4�and we haVe 10.0 Manufact�u�ing
no employees.[No workers'comp.insurance r�uired]* I I.�Health Care
4.❑ We are a non-profit organization,staffed by volunteess,
with no emgloyees.[No workers'comp.insurance req.] 12.0 Other
=Any applica�tbac�bmc#i�t also fiu out the�bdoNv showing t�e's vvorkas'�tion Poli�Y info�matiao,
s«if t�e c�rpora�e ot�s hsvt e�npted thesm�elves.bat the caporstion ha4 ottser r.mployces,a�voti�eis'ooa�P�IiaY is tequited aad sucl��
org�on shouid cLedc box�kl.
I um an e�lvyer thrrt isprovirlirig workers'Bampensa#iox insurance for my e►npioyees Belaw is the policy�iejormatron.
Inst�rance Compa�ty Name:
Insurer's Address:
City/StatelZip:
PoGcy#or Self-ins.Lic.# �p�an��
Attach a copy of the workers'compe�ttion poln.y dcclarstion Mge(s�owing the poli�.y nnmber xnd ezpiratiot date�
Failune to secure coverage as requir�ed�md�Sedion 25A of MGL c. 152 can lead to the imposition of cximinal pe�alties af a
fine up to 51,500.00 andJor on�-year imprisonmetrt,as well as civil penalties in the form of a ST'OP WORK ORDER and a fine
of up to$250.04 a day against the violator. Be advised that a copy of this statement may be forwarded ta the Office of
Investigations of the DIA for insurance coverage verification.
I do herehy eerti�p,u the pains�r»d pt�raltits of perjr�ry that the infornwtios pravided abov�e is�e and coner.�
i Date: �� (gj �
P�OIIe#�' a (J `���� ���C�
0,,�9clal�se oRty. Db not write ix th�c areu,m be conyule�ed by citp or town officia�
City or Towa: PermitlLicense#
Issni�g Aatl�ority(rirele oae):
1.Board of Health 2.Bailding Departmeat 3.CityrTown Clerk 4.Lice�sin.g Board 5.Selectmen's Office
6.Other
Co'tsct Person: Phone#:
www.mags.gov/dia