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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�e�ber 16 2�016,. Failure to do so will result in the return of your applicahon packet. ESTABLISHIvv�ENT NAME: � � • o LOCATION ADDRESS: 1�{� �N kL� Pa,'4�. �r.#• 5oe•3q4•3 5 i� MAILING ADDRESS: E-MAII,ADDRESS:_��_ W1.►d.�tht o�.'�� c.�.• c�o rr� OWNER NAME: �lu� o� "(�7,.�,5 , . CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: �Q�parF /�l�Q.{�v�1s T'EL.#: �j• 23Z-9405 MAILING ADDRESS: �i�1 uu�o_ POOL CERTTFICATIONS: The pool superviaor 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. l. ��cX'� /v1fC.le�� 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community rr i � `� , Caniiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the `-" n '; � employees below and attach copies of their cemfications to this form.The Health Department will not nse past =-! N � :; years'records. You must provide new copies and maintain a file at your place of business. � W �'"�� 1. �wb�t-t- Ma ie�sV.,' 2. � o F� 3. 4. --� rn ��.� FOOD PROTEC'ITON MANAGERS-CERT'IFICATIONS: 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. : You must provide new copies and maiutxin a file at your establishment. i. .-.�o`f�. �� 2. , � PERSON IN CHARGE: �.,�:��; Each food establishment must have ai teast one Person In Charge(PIC)on site during hours of operarion. �� C2 ��E /�4+P.��JS� ;:ry. . 1._� �� 2._ �t. �'_ ALLERGEN CER'TIFICATIONS: 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(Gx3)(a). Please attach � � copies of certification to this application. The HeAlth Department will not use past years'records. You must � �C� provide new copies and maintain a�le at your esta6lishment. �!-,_� , 1. 2. ' HEIMLICH CERTIFICATIONS: All food service establislunents 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 pr�edures below and attach copies of employ�certifications to this form. The He,alth Department will not use past years'records. Yoa must prnvide new copies and maintain a fite at your place of business. 1._�b�eV� �ec+J S�Q.e' 2, �1 C�h.6�. ��-t J�,�.�..,Yf'�C,' 3.--��e ��.- 4. �� RESTAURANT SEATING: TOTAT.,# 2'a' Lo�nvs: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQ[lIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# �B S55 CABIN S55 M07EI. 5110 � SSS CAMP S55 SWIMMING POOL S110ea � =1-ODGE SSS _'IRAILERPARK 5105 �WHIRI.POOL SllOea�l� -r r /- .. F'OOD SERVICE: �aN��D a��;j1-�-4�I3� LICCONTINENTAL p S35 PF.RMTt# LICNON-P O�IT� $30 PERMIT�! >I00 SEA7'S 5200 � �COMMON VIC. S60 �g, =WIIOLESALE S80 RETAIL SERVICE: —RESm.KITCHEN S80 LICENSE REQU[RED FEE PERMIT# LICENSE REQ[JIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50sq R. SSO >25,000 R 5285 VENDiNG-FOQD S25 45,OOOsq.R 5154 =FROZEN�ESSERT S40 =TOBACCO 5110 NAME CAANGE: S15 AMOUNT DUE = S �.-1S r Q� *'•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**t" p�{�F-��-03 Su-03 anr�sP�c�l—o��6-63 , 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 Wo�rlcer's Compensation Insurance. THE ATTACHED STATE WORI�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR , CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVTI'SIGNED AND ATTACHED Town af Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPILOPRIATELY IF PAID: YES NO MOTELS AND 01'HER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the lunitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occugancy,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 tcansient. Occupancy that is subject to the collecrion of Room Occupancy Excise,as definefl in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be consideretil Transient. POOLS POOL OPENIlVG: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 schedale the inspection three(3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TES'1'Il�1G: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Deparmnent three(3)days prior to opening,and quarterly thereat�er. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPE1�iING: 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 Yarmouth Health Departrnent by filing the reqwred Tempo Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the H�th Department,or from the Town's website at www.yarmouth.ma.us.under H�Ith Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and montlily thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Fmzen Dessert Permit until the above tetms 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. i � NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR ItESPONSIBILTTY TO RET[JRN 1`HE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ; � �' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTIlVG, NEW i � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO CO�NCE NT. RENOVATIONS MAY REQUIItE A STfE PLAN. DATE: � I(O SIGNATURE: �O�-� E— ' PRINTNAME&TITLE: ��'eY� 1Y�,QU�2�u.�C�.. '�`�-Std� Rev.10l12/t6 ; I NOTICE �, NOTICE TO ��_ TO . EMPLOYEES EMPLOYEES � The Commonwealth of Mas k sachusetts . DEPARTME1v'T OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727=49U0-http://www:mass.gov/dia As required by Massachusetts Genera Law, Chapter 152, Sections 21,22, 30;this will give you notice that I(we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: Technology Insurance Compariy ' NAIVIE.;OF INSURANGE COMFANY . . 800 Superior Avenue East,2.l st F1oor, Cleveland, OH 44114 ADDRESS.OR INSURANCE COMPANY TWC3495356 9/20/2016 to 9/20/2017= POLICY NUMBER EFFECTIVE DATES ` One'Bala Plaza,#100,Bala Cynwyd,PA Valley Forge Insurance Brokerage: 19004' (800)873-4552 � NAME OF INSL7RANCE AGENT ADDRESS PHONE# , Mid-Cape Racquet&Health 193 White's Path, S Yarmouth,MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of , employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the. services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospita.l attention,employees are � hereliy notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER