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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 2016. Failure to do so will result in the return of your applicahon pac cet. ' ESTABLISHMENT NAME:� ' 'F tr' C- — •5 ; ' LOCATIONADDRESS: f'L � 1 �' �� `��N r" TEL.#: ' '-' � —" '�/ I MAILING ADDRESS: �vc��X— E-MAIL ADDRESS: - "� t�a a-', Ga. •L`� :r'b� OWNER NAME: '� t - •^-�t- CORPORATION NAME(IF APPLICABLE): � r c ' `�l�=Y- C_; ' MANAGER'S NAME: TEL.#: 2 C� � MAILING ADDRESS: � �ti � � I'�`1 r C"3 j POOL CBRTIFICATIONS: = f� �i'1 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 eopy of the ' cation to this form. � � � � � �' r� , i. � 2. -� � � � Pool operators must list a minimum o two employees cuirently certified in standard First Aid and Community i Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of theu certifications to tlus form.The Health Deparlment will not use past � years'records. You must provide new copi and maintain a file at your place of bnsiness. i i1. 2, ,._ . . ., � 3. 4. -, ; �' FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establistunents are required to have at least one full-time employee who is certified as a Food Protection Manager,as deSned in the State Sanitary Code for Food Service Establishments, l OS CMR 590.000. ;, � Please attach copies of certification to this application. The Health Department will not use past years'records. J, You must provide new copies�nd mainta' f�t your est�blishment. � 1 2 � . PERSON IN CHARGE: Each food establishment must have at least one Pe In Chazge(PIC)on site during hours of operation. 1. 2. ALLERGEN CER'I'�ICATIONS: O All food service establishments are required to have at least one full-time employee who has Allergen certification, s' as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach y copies of certification to this application. T6e Aealth eparlment will not use past years'records. You mast ,� provide new copies and maintain a fde at your bl�h_ment � 1. //� 2. HEIlvILICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich W Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this f Th�Health Department will not use p�st y�rs'records. You must provide new copies and maintai��at your place of basiness. �(�/ 1. i` 2. 3. 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE T'ERMIT# B&B S55 CABIN $55 MOTEL $110 �IT1h1 $55 CAMP S55 _SW[MMING POOL S110ea �.ODGE S55 �TRAILERPARK $105 ��(—,� ( _WHIRLPOOL SllOea. FOOD SERVICE: LICENSE REQUIItED FEE PERMIT i! LICENSE REQUIRED FEE PF..RMIT# LICENSE REpUIRED FEE PERMIT# _0-]OOSEAI'S SI25 _CONTINENTAI. S35 NON-PROfIT S30 _>100 SEATS 5200 _COMMON VIC. EGO WHOLESALE $80 �RESID.KITCfIEN S80 RETAIL SERV[CE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT iF LICENSE REQUIRED FEE PERMIT# <50sq ft. $50 >25,000sq R 5285 VENDING-FOOD S25 =<25,000 sq.R a150 �ROZEN DESSERT S40 TOBACCO SI10 NAME CHANGE: a15 AMOUNT DUE = S_/05.0� *"*••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'** ir ! � ; ADMIrTISTRATION � ( 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 dces not have a Certificate of Woxker'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.AFFIDAVTI'SIGNED AND ATTACHED Town of Yarmouth taa{es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES x,/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Txansient occupancy shali be limited to the temporary and short terra 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 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Deparlment to schedule the inspection three(3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area un61 the pool has been ' inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count , by a State certified Iab,and submitted to the Health Department three(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 OPErTING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the ' Health Department to schedu(e the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Tempo Food Service AppIication form 72 hours prior to the catered event. T'hese forms can be obtained at the H�th Department,or from the Town's website at www.yarmouth.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. Fazlure to do so will result in the suspension or revocation of your Frozen Dessert Perinit until 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 COOKING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited. , NOTICE:Pemuts run annually from January 1 to Decembar 31. Tl'IS YOUR RESPONSIBILTTY 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., PAINTING, NEW ' , EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMMENCE NT. RENOVATIONS MAY RE A STTE PLAl�j DATE: � � a� SIGNATURE: ' C�(,-( � �� L'c ��=Z�-- � ' PRINT NAIv�&TITLE: CxT" L� 1 �t Rev.iaivie 1 � � The Co»unonwealth ofMassachusetts � Deparbnent of Industrial Accidents � O,fj`'ice oflnvestigations 1 Congress Stree�Suite 100 � Boston,MA D2114-2017. ; www mass gov/dia ; Workers' Compensation Insurance Affidavit: General Businesses � AAplicant Information Please Print Le�iblv l 3 I, BusinesslOrganizationName: ��;��r� /r�'?�; , �� i � -� ; Address: /�r� /r ��:� ��' - ,' ' �1 � C i City/State/Zip: - ��S � � l�1�" Phone#: _j L� ��J��C� l � � Are you an employer?Check the appropriate boa: Business Type(required}: ' 1.❑ I am a employer with employees(full and/ 5. ❑Retail � ,��9 r part-time).* 6. ❑RestaurantBar/Eating Establishment i2.L�" I am a sole pmprietor or partnership and have no �, � p��a/or Sales(incl.real estate,suto,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 '; no employees. [No workers'comp.insurance required]* 4.❑ We are a non-profit organization,staffed by volunte�rs, 11.�Health Care jwith no employees. [No wc�kers' comp.insurance req.J 12.�(�her /j2i 1��1'� /�f^�� "Any applicant that checks box#1 must also fill out the section below showing tbeir workers'compensation policy infotmation. *'If the corpoiate offi�rs have exempted themselves,but the corporation has othes employees,a workers'compensation policy is lequired aad such an organizaUan should checic box#1. � I am an emp[oyer that isproviding workers'compensation insuranee for my employeeS Below is thepol�cy informatfon. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy d�laration page(showing the policy nnmber and ezpiration date). Failure to secure covera,ge 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 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00?a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investiga#ions of the DIA for insurance coverage verification. I do hereby certify inder the pains and pe�ofperjury that the information provided abov is true and correct. Sigt►a tre: � �%%�.�� L- Date: l� �•� Phone#: �C�'�...1�f�r� C'� � � Official use only. Do not write in this area,to be co»�plded by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cierk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia