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Home My WebLink AboutApplication and WC� . .. ` � ' -- -___ ��d� d TOWN OF YARMOUTH BOARD OF I�ALTH �� 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 applicarion pac et. ESTABLISHMENTNAME: � S o 5 - /2 LOCATION ADDRESS• 2�! ,� �,rr,-r� �l�IfEL.#: o - � - vzg MAILING ADDRESS: C.c /r1-v� � U-�c o �uT] 0 -� E-MAIL ADDREs s: C 1 r--� Lj c, „-r+ OWNERNAI�: h./r9 CORPORATION NAME(IF APPLICABLE):C��c r{r�4 � ?rt P C Lto�o S 1•�e . = G� � MANAGER'S NAME:__St�Sc�r� �c.�r t �-t TEL.#: Q- � � � MAILING ADDRESS:_�_�� L-,�n� ��p . ��.,,,,.,� ..:� b�o�r � `— _ �'''� Ell POOL CERTIFICATIONS: 1�1 P'� 0 i� ;� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated -D a � 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 Heatt6 Department will not use past � years'records. You must provide new copies and maintain a fde at your place of business. 1 2 �F—�j 3. 4. � �- ; _ . �. � FOOD PROTECTION MANAGER$-CERTIFICATIONS: Cj2,l t �(y 7�r�.�u C�4 jt� �fitl L� S- � ' All food service establishments are required to have at least one full-time empldyee who is certified as a Food '� ' � Protection Mana er as defined in the State Sani � � g , tary Code for Food Service Establishments, 105 CMR 590.000. � Please attach copies of certification to tlus apptication. The Aealth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2' � PERSON IN CHARGE: Yu � � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � 1. Z, � -G ALLERGEN CERTIFICATIONS: N� 6` All food service establishments are required to have at least one full-time employee who has Allergen certification, d as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach N 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, HEIMLICH CERTIFICATIONS: N� A�i food service e ' ' 33�s'��or��iust�aTleas�one emp7oyee�raine�tn the Heimlich " Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificarions to this form. T6e Health Departmeut wIll not use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 1! LICENSE REQUIRED FEE PERMIT li —B�B S55 CABIN S55 M07'EL 5110 � SSS CAMP a55 _SWIMMING POOL SI l0ea. =LODGE $55 �TRAILER PARK SI05 _WHiRI,pOOL S110ea. FOOD SERVICE: LICENSE REQUIItED FEE PERMTT# LICENSE REQUIREp FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS 5125 _CONTINENTAL 535 NON-PROFIT S30 _>!OO SEATS $200 _COMMON VIC. S60 —WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMCC# LICENSE REQUIRED FEE PERMIT# <50 s .ft. S50 >25,000 ft. 5285 VENDING-FOOD S25 ��5>�� a150 �I.�Z —FROZEN�ESSERT S40 _TOBACCO 5110 NAME CHANGE: S[S , AMOUNT DUE _ $ �5 O 'dC� **•*�'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**••* , ` i r , ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold iss�ance or renewal of any license or permit to operate a business if a person or company dces 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 pertnits. 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 hotei 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(3Q�days,an.d_ __ __.,_ an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dweiling 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 tLree(3) days prior to opening.PLEASE NOTE:People are NOT aliowed to sit in the pool area until the pool has been ! inspected and opened. 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 CLO5ING:Every outdaor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Atl food service estabiishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspecdon three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service App[ication form 72 hours prior to the catered event. These forms can be obtained at the Health Departtnent,or from the Town's website at www.varmouth.ma.us under Health Deparhnent, Downloadahle 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 Permit unril 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,preparation,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. I'�'IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR O (i.e., PAINTING, NEW ' ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPRO ED BY T B ARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A�I P ' DATE: SIGNATURE: � PRINT NAME&TITLE: / �C.S Rev.10/l2/I6 r • �' ` � � The Commonwealth of Massachuseits Depart»�ent of Industrial Accidents Office of Investigations ' I Congress Street,Suite 100 Boston,MA 02114-2017 www ma.ss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apalicant Information ' Please Print Le�iblv Business/Organization Name: �ht iS�yY1� ` `�"�'e e � �d�'-S l� . Address:�� '� F City/Sta.te/Zip: tUy`. U��( 3 Phone#: �UP� - � ��- 0��'� Are u an employer?Check the appropriate boz: Busin Type(required): 1. I am a employer with�employees(full and/ 5. Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or 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 required)* 11.�Hea1th Care ';� 4.❑ We are a non-profit organization,staffed by volunte�rs, iwith no employees. [No workers' comp.insurance rey.] 12.0 Other 'Any applicaut that chedcs box#1 must aiso fill out the secdon below showing tbeir workers'compensation policy information. '*If the corporate of�rcers have exemptsd themselves,but the corporation has other employees,a workers'compensation policy is required and such� organization should check box#1. I am an emptoyer that is provi 'ng workers'compensation insurance f my employees Below u the policy�ieformation. Insurance Company Name: C��`� �1 ��(.`��ct Insurer's Address: ��(, �� - City/State/Zip: / �✓L� !�V �� /V� /U(� l � Policy#or Self-ins.Lic.# L�S �7 b[ '� �D 2 Expirarion Date: � � � � Attach a copy of the workers'compensation policy declaration page(showing the policy nnmber an ezpirntion date). __�'�ilure ta see�u��$�ev�rage a��t��er-�eetian�5�4vfiVffi�L-c�eair leadto . . . . . penatti�cyfa---- - _ 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 O�ice of Investigations of the DIA f insurance coverage verification. I do hereby certify,u th pains andpenalties ofperjury that the information provided above is true and correct. Si ature: Date: 1 C) a� �JF' Phone#: - (D ��— ��F Official use orcly. Do not write in this area,to be contpleted by city or town offaciat City or Town• Permit/License# Issuing Authority(circle one): 1.Board of HealtL 2.Bnilding Department 3.City/Towu Cterk 4.Licenaiag Board 5.Selectmen's Office 6.Other Contact Person: ' Phone#• www.mass.gov/dia