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Home My WebLink AboutApplication and WCr , atA�Pc.�w�QD � . � y TOWN OF YARMOUTH BOARD OF HEAL H ��GE��1�� Y�W��°�• ' � " � APPLICATION FOR LICENSE/PERMIT-2 17 �, o,,.. +1�k,r`� ; �� °�t'�f=� `'%r� * Please complete form and attach all necessary documents by ISecember'16 201 . Failure to do so will result in the return of your app 'cat' �.k ��T1=f��PT. ESTABLISHMENT NAME: �td t TAX ID: LOCATION ADDRESS: �`7 � lGt � " TEL.#: ' -�� i MAILING ADDRESS. v 6 t� " 3 Z- ! ' E-MAIL ADDRESS: l�'�.e.� �a � �':.� � OWNER NAME: cL �L L �. • ` �f. -` ' CORPORATION NAME (IF APPLICABLE): �t � ; . MANAGER�S NAME: � ��r�r EL.#: ; - p �- �p MAILING ADDRESS• I�1 DZ��2.. , POOL CERTIFICATIONS: 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 copy of the certification to this form.._ _- ,-- - �- ,� � . . -- -__ - 2.__,�-� �'T��--;_ _ __ 1 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 i �y ' record�You must provide new copies and maintain a file at your place of business. 1. 1Z2.� 2. �►2�J�"'1">4-L (�,�,�/I I Z. 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 Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. �'-o�`i ust pr ' ew copies and maintain a file at your establishment. 1. �� C�it 2. I�N' ` �'�UC�C � PERSON IN CHARGE: ood establishment must have at least one Person In Charge (PIC) on site during hours of operation. / 1. f- 2 �� <,�Vll.� 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 __ �� e new co ies and maintain a file at your establishment. , 1 2. A-�f 14 �lX� I��li(.�e 1/ 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�lace of business. 1 2. �C�/Cp. 3. 4. RESTAURA SEATING: TOTAL# I Z�I- �� --- C�FFICE �.iSE ONLY ' .. ... - ---------- -- — LICENSE REQUIRED FEE PER'v1IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —B&B $55 _��P $55 MOTEL $110 _I� $55 =SWIMMING POOL$110ea. �7- 7 LODGE _TRAILER PAItK $$OS ___[_WHIRLPOOL $110ea. #/7-p// FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �>100 A SS $200 CONTINENTAL $35 NON-PROFIT $30 (�� COMMON VIC. $60 .. �� —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.i�. $285 VENDING-FOOD $25 � �<25,000 sq.ft. $150 � �FROZEN DESSERT $40 � _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ �30. Od *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*��D+►5P-t5-�Sa2-6L �wel P�o►�SP-�5-�9o3-aL Bo►t F�l5-18b5'� Ccws� 6oNP-�f►�� r 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 V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � � Town of Yarmouth t�es and liens must be paid p iar to renewal or issuance of;�our 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 sha11 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 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 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 TESTING: The 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 ar covered within seven(7)days of closing. 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 Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health 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. Failure to do so will result in the suspension or revocation of your Frozen ' Dessert Permit until the above terms have been met. OUTSIDE CAFES: � �utside 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. IT 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 POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AP VED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY SITE PLAN. DATE: � � SIGNATU PRINT NAME& TITLE: � �� e� Rev. 10/12/16 Zo5�21� � �� ,�`. NOT'ICE NOTICE TO d TO EMPLOYEES t EMPLOYEES , ,,•�' V � The Commonvvealth of Massachusetts � DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts Genera.l Law, Chapter 152, Sections 21,22&30,this will give you notice that I(we)h�ve provide�d for payment to our injured employees under the above-mentioned cha ter b P Y insuring with: MEMiC Indemnity Comp�ny NAA�iE OF INSURANCE COMI'ANY 1750 Ekn SV�t, M�nche�ter, NH 03104 ADDRESS OF INSURANCE COMPANY 3102804�8 6/1/2016-5/31/2017 POLICY NUMBER EFFECTIVE DATES M&T 101 S. S�lina St.,4th FI., Syracx��e, NY 13202 NAME OF INSURANCE AGENT ADDRESS PHONE# Mapl�wood at A�yflowvsr Pt� 879 Buck Island Road,W Y�trricwEh M/►Q2673 EMPLOYER ADDRESS 6/1/2016 EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above n�med insurer is required in cases of personal injuries arising out of and in the course of employment to ftuYsish adequate and reasonable hospital and medical services in accordance with the provisions of the Worlcers' 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 ser- vices 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 hospital attention, employees are hereby notified that the insurer has arranged for such attention at the CareweN Urgent Carea Patriot Square,484 Rte 134 NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER