The URL can be used to link to this page

Home My WebLink AboutApplication and WC, TOWN OF YARMOUTH BOARD OF HEALTH d� 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 application pac cet. i ESTABLISHMENTNAME X Churc Paris i � j ; LOCATION ADDRESS:�g�}-1��?�Quth, MA TEL.#�0 8-3 9 8-2 2 4 8 MAtLING ADDRESS: 5 Barbara S , 3 Yarmou�" �vz6 , E-MAILADDRESS: G�ni nGxoffi cP(dcomcast.net OWNER NAME: A�-A�as e e#� Fa l 1 R i ve r CORPORATIONNAME(IFAPPLICABLE)�nman C'atholic BishoA Of F811R1VeI' MANAGER'SNAME: ��ev 6eR�ge C Bellpnait 'I'EL•#: 508-398-2248 MAiLINGADDRESS:_s___�p�� e�� 4� 02664 = � � � .�� POOL CERTIFICATIONS: r 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 certification to this form. 0 t�a r-.� 1. 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�t your place of business. 1. 2. � 'v�� 3. 4. �� i ��I FOOD PROTECTTON 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 Establishments, 105 CMR 590.000. � Please attach copies of certification to this application. The Health Department will not use past years'records. �y_ �M� I. You must provide new copies and maintain a file at your establishment. fr. � 1. C�Pnrqe F;nn 2. Steve Sozanski . � ' �. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1._ 8��1—L1�-�o. 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�Ie at your establishraent. 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 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. i._ Georae Finn 2, Ben Volpe 3. l�an l�ntc� 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��B S55 CABIN SSS _MOT'EL $I IO �.ODGE $55 �'°`MP S55 _SWIMMING POOL Sl l0ea =TRAILERPARK 5105 _WHIRLPpOL SllOea. FOOD SERVICE: LICENSE REQQQ.U,,�_,IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RN I ?, a�OS��, �� _,CO MONrVIC E60 �WHOLE3ALE �80� ��✓ RETAILSERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. S50 >25,000 sq.ft. $285 VENDING-FOOD S25 _QS,OOOsq.ft. 5150 =FROZENDESSERT S40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ � �p,�3Q : •'"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"" Q�r-�s- sgssroZ , ADMINISTRATION 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 COMPLETED AND SIGNED,OR , CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED , Town of Yarmouth taxes and liens 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 shatl 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 shall generally refer to continuous occupancy of not more than tlurty(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 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. j POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate count , by a State certified lab, 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. i FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All 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 Yazmouth Health Department by filing the required Tempo Food Service Application 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.�annouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and mottthly thereaRer,with sample results submitted to the Health Department. Failure to do so will result m the suspension ar revocation of your Frozen Dessert Permit 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 Boazd of Health. j OUTDOOR COOKING: i Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. � , ; NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN , THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � i ' ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMMENCEMENT. RENOVATIONS MAY REQU/�A SITE PLA�� ' DAT'E: ��"�' /� SIGNATURE: "' � � PRIN'T NAME&TITLE: �� C/fi/Li5 �Sc.x+"t�, A4ti(iN/STit.�l� : Rev.to/12/16 i � F . � The Commonwealth ofMassachuseits Department of Industrial Accidents Offace of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv Business/OrganizationName: st. Pius x church Parish, Life CentPr Address: 5 Barbara Street City/State/Zip: South Yarmouth, MA 02665 phone#:508-398-2248 Are you an employer?Check the appropriate bog: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ Resta.urant7Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office andlor Sales(incl.real estate,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 ' no employees. [No workers' comp.insurance requiredJ* 4.� We are a non-profit organization,staffed by volunteers, 11.Q Health Care with no employees. [No workers' comp.insurance req.] 12.� Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informaiion. *'If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such aa organi2ation should chedc box#1. I am an employer that is providing workers'compensation insurance for my employees Below is the pollcy information. Inswance Company Name: Inswer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 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 Invesfigations of the DIA for insurance coverage verification. I do hereby certi n the pains and penalties of perjury that the�nformation provided above is true and correct. Si a �� ' %� Da �� /� te: PhQne#: 508-398-2248 Official use only. Do not write in thu area,to be completed by city or town official City or Town: PermifJLicense# Issuing Authority(circle one): 1.Board of Health 2.Buildiug Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia