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Home My WebLink AboutApplication and WC R�C�IVED � a TOWN OF YARMOUTH BOARD OF HE�TI�' � �� ; .;, ��, � - „ � � APPLICATION FOR LICENSE/P '� � %� � E,"� � �� * �� ,,�� Please complete form and attach all necessary�iQc � ��y�cem er 1 DEPT. Failure to do so will result in the return o�your application pac e . � ESTABLISHMENTNAME: /h�9c.cAF PKov�.s,o,,,c,.s � T�X ID•�01� .�3� 4 r�,t � LOCATION ADDRESS: �/- �7 F.<v.��.�I q vE TEL#•.So�- 7G o_ 0 4-�7 - MAILING ADDRESS: �� I . �/i9 R�o t�y��.A o� 6 G� ; E-MAIL ADDRESS: s'�C s7 �?9 c.C.o�c �R p v�.p�,o,�tl.7'. c o�✓J OWNER NAME: �+'l A•� �'i.✓ ��c•CA E ��N.��'� c'o p�1'E CORPORATION NAME(IF APPLICABLE): C R o/t�F -�yj qc�c.�v E �.r�c MANAGER'S NAME:1_�.9R•t y �o o,�-E TEL.#• .s-Q �� MAILING ADDRESS: cs'.�.r�� . .:� POOL CERTIFICATIONS: The pool sup�rK�se��b��as a Pavl-�tez•,ss rr.�uir�c3-by-State-ta�t:-�leas�list th�d��ignated - Pool Operator(s)and attach a eopy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary 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 Department will not use past years' records. You must provide new copies and maintain a file at yaur place of business. 1. 2, 3. � 4. FOOD 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 Esta.blishments, 105 CMR 590.000. Please attach copies of cerrification to this application. The Health Department will not use past years'reeords. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 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 CMR 590.009(G}(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment.. 1. 2, HEIlVILICH CERT'IFICATIONS: 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. Flease list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. 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. w�ro�.vsa� goti1-1�-1 -a 2-OZ RESTAURANT SEATING: TOTAL# �`�2� OFFICE USE ONLY LODGWG: ' T.iC.F.NSF.RFni�iRF.T) FFF PFAf1ATTH rrrrT.rc�n�nTTm�n Fpi7 DCDR.fTTA fTl�pUTOFDL`f1iTTl]Fn TJS."L7 DCD1liTY { ADMINISTRA,TION 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 does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE CUMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED_� Town of Yarmouth taxes and tiens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: _ _ YES�— _ ___ 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 elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty(30)ilays,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 OPEIVING: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 Department to schedule 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 inspected and opened. � POOL WATER TESTIIVG: The water must be tested for pseudomonas,total coliform and standard piate eount by a State certified lab, and submitted to the Healtla Department three ;3) �ays�rior to�pening, anc�.qu�rterly : � thereafter. ; POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Atl 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�armouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be� obtained at the Health Department,or from the Town's website at www.Yarmouth.ma.us under Health Department, Downloada.ble 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. Failure to do so will result in the suspension or revocation of your Frozen Dessert-i'errnit�tne abov�terms h�v�b�en met. - . _ _ __ _ OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/wa.itress service),must have prior approval from the Boazd of Health. j OUTDOOR COOICING: i Outdoor cooking,prepa.ration,or display of any food product by a retail or food service establishment is prohibited. , i � ?'he Commonwealth of Massachuseits Department of Industrial Accidents Office of Investigations ' 1 Congress Street,Suite 100 Boston,M�102114-2017 - www.mass gov/dia Workers' Compensation Insurance Affidavit: General Businesses ApAlicant Information Please Print Le�iblv Business/Organization Name: �o P '`lC �`�c'�q E �''�c �� ✓!�-�o*� Address: �/ - � �.Q y�y.�/ A✓E �� F4 � City/Sta.te/Zip: S� Yi9 •s�, p vi�/ �rJ� Phone#: ,�08- 7 4 m - a Sr..S 7 Are you an employer?Check the appropriate bog: Business Type(reqaired): 5. Rttai3-- __ _ ------ __ 1.{� I am a employer witFi-01�- emptoyees(full andT - fl or part-time).* 6. ❑Restaurant'lBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,suto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-pmfit 3.❑ We aze 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 volunteers, 11.�Health Caze with no employees. [No workers' comp.insurance req.] 12.�Uther ��`'rTR r•� v� < 'Any applicant that chedcs box#1 must also fill out the s�don below showing tbeir worke�s'compensation policy informaiion. ••If the corporate oPficeis have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should chedc box#1. ' I am an employer tkat is providing workers'compensatdon insurance for my employees Below ds the poltcy�njormation. Insurance Company Name: � � �E�-�-9 /�e/`S. Insurer's Address: �� 'Q o `�"� �'o � �N y ��. City/State/Zip: Q��/��✓C� �7� �� / Policy#or Self-ins.Lic.# ��`��`r�� S Expiration Date: l� " l"r' �� Attach a copy of the workers'compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage 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 VJORK 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 DTA for insurance coverage verification. I do hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct. i Date: �° � � � l�P Phone#: `r��` ` 7�Q- D�Os7 O,ff�cial use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# Issaing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board_5.Selectmen's Office_ _____ _ -�.IIt�er - - - - --- Contact Person• Phone#• www.mass.govldia