HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2017
"Please complete form and aztach atl necessary documents by� 16 20I6.
Failure to do so will result in the retum of your applicahon pac et.
ESTABLISHMENT NAME: �y .r a • Otr • (� - 6
LOCATIONADDRESS: 4?a�'s 'SED-���.. � S. u�. .�.� /�N�c 0:�6t4'TEL#• �u �61�-36'� � �? ��'�CI
; MAII.ING ADDRF,SS: � � �
E-MAIL ADDRESS: i.,�ak,�,. .^�.X`� ���.�t�. �,o�n = � m
O WI�IER NAME:__�'Rh'!'�. W��t�.w. ' e
CORPORATION NAME(IF APPLICABLE): w►1,J �n • ^ � �m � rn
MANAGER'S NAME: P�1F'��., LJdk�ti. TEL#• i4o i� �"I�y�3C� .—�I � v
MAILING ADDRESS: L`33 T�ix.� �0...L ��, ��,,,.,� ,� :N`/t 026�'� ��
POOL CERTiFICATIONS:
The pool aupervieor muat be certified xs a Pool Operator,as required by Stnte law. Piease list the designatcd
Pool Operator(s)and attach a copy of the certification to this form.
i. 2,
Poot operators must list a minimurn of two employets currently certified in standard First Aid and Community
Cardioputmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form.The Health Departroent will not use past
years'rtcoMa. You mnat provide new copies and maintatn A!lle at yonr place of bueiness.
(. 2. �
3. 4. �
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FOOD PROTECTTON MANAGERS-CERTIFICATIONS:
Alt food service establishments are requireci to have at least one full-time employea who is certified as a Food
Protection Manager,as defined in the State Sanitary Code for Food Service Estabtishments, 105 CMR 590.000. "
Please attach copies of certification to this appiication. The Health Department will not use past yeAra'records.
You must prnvide new copies and maintaia a file At your estAbtishment.
I. 2. G>
o�
PERSON IN CHARGE: �
T
Each food establishment must t�ave at least one Person In Charge(PIC)on site during hours of operation. !
�
1. 2, �
D
ALLERGEN CERTIFICATIONS: ,rNj
All food service establishments are required to have at least one ful l-time empioyee who has Allergen cenification, �
as defined in the State Sanitary Code for Food Service Establis6ments,105 CMR 590.009(G}(3xa). Please attach N
copies of certification to this application. T6e Health Department will not use past yexrs'reeords. You must
provide new copies and maintain a tile at your estabtishment.
1. 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�xocedures below and
attach copies of employee certificadons to this form. The Health Department will not use past years'recoMa.
You muet prnvide new copies aud maintain a file at your place of busfoess.
1. 2
3. 4.
RESTAURANT SEA'i`ING: TOTAL#
WDCRYG:
OFFICE ilSE UNI.Y
LICENSE REQUIRED FEE PERMiT# LlCENSE RGQUIRI�D ��E P�RMt'T M L(C.ENSF.REQUtRED FEE PF:Rb([T M
—.,�N SSS CARIN SSS _ _ MO't'F:L SI10
�.ODGE sss - - _.._ _SWIMMtNG POOL SI IOw. �
�CAMP f55
_TRAILfiR PARK StOS __ .__WHIRLP'OOL S!IOea
FOOD SERVICE: � �
L[CENSE REQU.�,[RED FEE P�RMIT p WCF.NSG RF.QUIRF.D FEE PCRMtT N LtCENSE RL UIRED FEF PERMIT B
_a��SE�.�.'�' �� ,CONTINENTAL S3S __. _ NON-PRO�IT S30
_�COMMON VIC. S60 �_ �WH()LESALE f80 ��
RETAIL SERVICE: � —1tESID.KfTCHEN s80 '"
LICENSE REQUIRED FEE P iT# LICENSE REQUIRt:p PEE PERMiT# LICENSF.REQU[RED FEE PGRMIT x
1<30sq R S50 >25,00(1sq fl. E285 VENDING•FOOD S23
___<25,OOp sq,R. SISO __� =FROZ.EN pESSERT �40 - �`!'UDACCU 51 t0
NAMECHANGE: SIS AMOUNTDUE � �_��'j.�� '
•'"rpLF.ASE TURN OYER AND COMPLETE OTHER SIDE OF FORlW►...«
ADMIN[STRATiON
Under Ct�apter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any licensc or pecmit to operate a business if a person or company dces not have a Certificate of Worker's
Compensation ]nsurance. THE ATTACHED STATE WORKER'S COMPENSATION TNSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OE'MSURANCE ATTACHF.D
OR
WORKER'S COMP.AFFinAVIT SIGNED AND ATTACNED
Town of Yarmouth laues and liens must be paid prior to renewal or essuance of y�ur petmits. PLEASE CHECK
APPROPRIATfsI.Y IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLiSHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient cecupancy shall be
limitcsd 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 shalt generaliy refer to continuous occupancy of not more than thirty(30)days,and
an a�gregate of not more than ninety(90)days within any six(6)manth periai. Use of a guest unit as a residenoe or
dwelling unit shall not be considered transient. Ckcupancy that is subject to the collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 GMR 64G,as ame�ded,shatl genera(ly be considered Transient.
POOLS
POOL OPENING:Ail swimming,wading and whirlpools which have been clnsed for the xa4on must be inspected
by the Heatth Department prior to opening. Contact the Health Department to schedule the inapecqon t6ree(3)
daya prior to opening.PLEASE NOTE:People are NOT allowed to sit in the poal area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,tntal coliform and standard plate count
by a State certified tab, and submitted to the Health Department three(3)days prior to opening,and quarterly
thereafter.
FOOL CLOSING:Fvery autdoor in graund swimming pool must be drained ar covered within seven(�)days of
closing.
FOOD SF,RVICF,
SEASONAL FOOD SERVICE OPENING:
Ati 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 Town of Yarmouth must notify the Yarmouth Health Department by fling the
required Temporary Eood Service Application form 72 hours prior to the catered event. These forms ean be
obta�ned at the Health Department,or from the Town's website at www.y�,rniouth.ma.us under Health Departcnent,
Downloadable Farms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sampie resutts
submitted to the Heaith DepaM�cnt. �'ailure to do so will result m the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waitedwaitress service),must have prior approval from the Board of Heatth.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service estabiishment is prohibited.
NOTICE:Permits run annually from January 1 to I�cember 31. IT IS YnUR RESI'ON5IBiLITY TO RETURN
THE COMFLETED RENEWAL APPLICATION(S)AND REQUIRED FGE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TO ANY FUOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUtPMGNT,ETC.),MUST BE REPOR7'ED TO AIvD AP!'ROVED BY THE BUARU OF HEALT'H PRIOR
TO GOMMENCEMENI'. RENOVAT[ONS MAY ` RE A SI"I'E PLAN.
DAT�: /(7':24—�� SIGNA"I'URE:, ,
---•
P[tINT NAME&TITLE: (�c.#rlw,., L.x.k.�w. — U`^'�
R�.io�iuib
� The Con�nonwealth of Massachusetts
Department ojl�dustrial Accidents
O,f,�'tce of Investigations
' l Congress Street,Suite 100
Boston,MA 02114-Z017
www muss.gov/dia
Workers' Compensafion Insurance Affidavit: General Businesses
Anoticant Information Please Print Legibiv
Business/Orgazuzation Name: �a�.�� �,re. �.�w
Address: M'�� '��:��. �
CitylStatelZip: �• y��..��. �/�A o2[t+� Phone #: o ��r- � 3
Are on an employer?Check t6e appropriate boz: Buslness Type(reqaired):
1.� 1 am a employer with � employees(ful!and/ 5. ❑ Retail
or part-time).* 6. ❑ RestauranVBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � p ff��d/or Sales(incL real estaie,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
1 no employees. [No workers'comp. insurance requiredJ* 11.(� Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with na employees.{No warkers'comp. insurance req.j 12.0 Other
"My applicant that chedcs box#i must al�fill out the section betow showing their woricers'compensatioa policy information.
s•If tl�e corpotate offioers have exempud them9elves.6ut the corporation has otha employxs,s workers'�mpensation policy is tequired and s�h an
o�ganizatio�s6ould chet�c box#I.
� I am an enrployer that is provlding workers'compensation insurance jor my employee� Btlow 3s the polky injormation.
� Insurance Company Name: '?l��e. `(�t�•�v�� �n�s,.�n•�c� (�m,.�am.r+��cs
Insurer's Address: P.�. (��,x �K 5�
CitylState/Zip: h'1�rJ►�kb��� /y1� v�3�H
.
� Policy#or Self-ins.Lic.# �T A�1�� �����' Expiration Date: d" '"���7
Attach a�py of the workers'compensation poUcy declaration pnge(s6owing the policy number and e=piration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the impasition of criminal penaldes of a
� fine up to�t,504.00 and/or one-year imprisonment,as well as civii penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,
I do hereby certl under the pains and penalt�es ojperJury that tl�e information provlded above is true and corree�
� � p �s ,�_�n G
Phon�#: �°'�� 6 ��- 3� 33
O,fj9c�a/use o»ly. Do not wrlte tn th}s area,to be completed by city or town o,J�`'rcla[
City or Town: PermitlLicense#
Issain�Aut6ority(circle onej:
1.Bos�rd of Heatth 2.Bailding Department 3.City/Town Clerk 4.Licensing Board 5.Setectmen's 4ffice
6.Other
Contact Person• P6one#:
www.mass.gov/dia
.�tco� C�RTIFICATE �F' LIABlLITY i�1SURANCE °"'�`�"`°°�"'
ti...� io��s��o�s
TttIS CER7IFICATE iS ISSUED AS A MATTER OF 1R�4R�ilAT10N QMLY AND CON�ERS NO RKs`HTS UP�N THf CERTiE1CATE MtQLdER. 3F�iS
CfRTlFlCA'TE �S NO7 AfFli�lATIYEtY t�i 11EtiA77YELY AlAEltD, EXTEliD t�R ALTER TFlE C�pVERAGE �►fFORDE[3 BY THE POLIGl��
BELC}W. TN15 CERTIFlCATE O� FNSURANGE DOES Nf3T CONSTIFl�TE A GaN3RACT SEtWEEN THE ISSilING lNSIfRER{S), At1THORIZEB
REPRESENTATIIlE t3R PRQIiUCER,AND TNE CfRTiFlCATE HOLDER.
tMFORTANT: !f U�e certfflcabe hokier is an ADDfT70NAL INSURED,�e�iteart#esj mnst be endorsed. 1#S1,lBROGATlON iS WANED,sut�jact to
the tem�s a�i cond#tions of#ie poNcy,cartain Fpiicles maY retWlre an andprser�t. A slatemerst an thiis cerflflcate does reot carFer r1gMs to tha
certlflcate holdar In Neu of such endo s).
RRoouc�t COKrwc�r Linda Caok
Oceanpoiat Insuranae Ageacy � , (d81)847-5204 F� ,��o�feaa-sovi
SAO ttest Main Rd �.levok@oeeanpvi.ntins,cts�
twsue ��c�s ��,uc r
ldiddletoxn RI 02�i� ��su�rtAfiravelers C$sual 6 Sure Y9t138
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x1�,1C�M ENTLRrRxsEs n1� n,sua�t c:
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' 445 Station Avenue �s:rrz�A�:
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� 90UTH YAIttlOUTH 2+�1 026�4 F�
CQNERAGES CERTiFtCATE NUMBER:CL161026Q1645 REVISfdN NttMBER:
tttlS IS T[7 CERTtFY TNRT THE PC?LICfE$p�li+[St3RANCE LISTED BELdW HAVE BEEN 1$SUED 7C3 TFfE tN3URED NAME�fhf3C31/E FOR T##E POLtCY P`ERtt�'3
� INDIGATED. NOTIMTH57ANDth1G ANY REQUIREMENT, TERM 4R CONE}iTKTN OF ANY GONTFtAGT OR t3THER DOCUMEt+tT 1MTH#tESP�CT TO WH1CH THlS
j CERTtFtC/4TE tAAY� ►�Su�L3 QR �Y PERTAtN, �L s(SiSURAtdCE A�FC7�ED BY`�t� �L3CfEs[sE�R#8ED NEREt� ts SC�6JE�T TGS Ali_Tti€TERMS.
EXGLUSN�MS ANQ Gf�lDITIC}NS O�SUCN P(3UCif8.LIMITS SHC}WN MAY HAVE ti€EN REt?U�ED BY PAID CLAiMS.
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