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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 Dece�mber 16 2016. Failure to do so will result in the return of your applicaUon pac cet. ESTABLISHMENT NAME: C T� - —3rj8' LOCATION ADDRESS:�7_j�;si�p \/i/��Q 9�iP 'S.S,��'EL.#: 56g 7 G p /�� MAILING ADDRESS• E-MAil ADDRESS: r�G' F» i� � OWNER NAME: CORPORATION NAME APPLICABLE) MANAGER'S NAME: TEL.#: �� MAII.,ING ADDRESS• �C 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 eopy of the certification to this form. t �. �;�oll�� ,�lr��-% 2.�`��s L� �ar-�' � �� Poo!operators must list a minimum of iwo employees currenfly certified in standard First Aid and Community � �-: �� Cardiopulmonary Resuscitation(CPR),having one cerkified employee on premises at all times. Please list the r ` �� employees below and attach copies of their certifications to tlus form.The Health Department will not use past T �"- �4 years'records. You must provide new copies and maintain�file at your place of business. — -•-- 1. ! 2. � � ,�Q/�/ � ,`.�' � 3. v 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. You must provide new copies and maintain s file at your establishment. �" �� 1. 2. , i� � �J` PERSON IN 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. HEIIvILICH CERTIFICATIONS: All food service establishments with 25 seats or more mvst have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LI ENSE REQUIRED FEE PE � sss cnn� sss �Mo�L a»o �'L gd y t,-�y-a�12S�o3 - �".ADGE SSS — - TRAILERPqRK $105 �v��ooi�Lsi�ioa��--�-7 6°��-14-0`t3l-6Z� FWD SERVICE: LICENSE REQUIItED FEE PERMIT# LI ENSE REQUIRED FEE ERMCf# LICENSE�Q UIRED FEE PERMIT# 0-100SEATS 5125 �CONTINENfAL S35 �_O�,I NON-PROFIT S30 >100 SEATS S2pp _COMMON VIC. S60 �VHOLESAI.E S80 $O�YF�I��{3�,,..03 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SOsq ft. SSO >25,000 ft. 5285 VENDING-FOOD S25 =�L5,000 sq.R 5150 �ROZEN�ESSERT S40 �1'OBACCO SI10 NAME CFIANGE: SIS AMOUNT DITE _ $ � � ****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**"* � ADMI1vISTRATION 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 Compensadon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR L �e;r,� �k�`�'Q/ 7� ,_. CERT.OF INSURANCE ATTACHED �vu ,�� SY�Y/�- OR �;, WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED� -�--"� �Q�� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your petmits. 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 shall generally refer to continuous occupancy of not more than thiriy(3U)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 tt►e season must be inspected by the Health Department prior to opening. Contact the Health Departm ent to schednle 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 Deparkment�(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. 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 openuig. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the requued Tempo Food Service AppTication 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.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly tt►ereafter,with sample results submitted to the Health Department. Fatlure to do so will result in the suspension or 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 Board of Health. j OUTDOOR COOKING: i, Outdoor cooking,preparation,or display of any food product by a retail or food service establishcnent is pro6ibited. � � NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. � � ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MO"i'EL OR POOL (i.e., PAIlVTING, NEW j � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMI��NCEMENT. RENOVATIONS MAY UIRE A STI'E PLAN. ; DATE: �� 02 9 ` SIGNATURE. .'_ Gli� PRINT NAME&TITLE: �i—` � �f'`T I`�S 4 t�.�a�vie i , � � The Commonweal'th ofMassachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Stree�Suite 100 Boston,MA 02I14-2017 www.mass.gov/dia Workers' Compens�tion Insurance Affidavit: General Businesses Aaalicant Information Please Print Legiblv Business/Organization Na,me:�/�� ..�y�� 1�Cc' Vi ��C�� D lc�/ Address: �7 �'�Zs�a�`P �,/�Cz�� City/State/Zip• � , Phone#: �D ' � — Are you an employer?Check the appropriate bog: Business Type(required): L,�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 Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] g• ❑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 �0.Q Manufacturing no emptoyees. [No workers'comp.insurance required]* 1 L�Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.� Uther •Any applic,ant that checks box#1 must also fill out the seciion below showing their workers'compensation policy information. •sIf the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should che�cic box#1. I am an employer that is providing workers'com,pensation insurance for my employees Below is the policy information. Insurance Company Name: �/YJ�'��t CIF� �f7 S, �-�s Inswer's Address: ��C> .�O�( �� y�� City/State/Zip: /��C��7�/�'l'�11�� ! c/ o�l� �f' � ' ��✓ Policy#or Self-ins.Lic.# ��GC/� `�`/��3� Expirati�n Date:� � Attach a copy of the workers'compensation policy declaration page(showing the policy nnm r and espiration 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 Of�ice of Investigations of the DIA for insurance coverage verification. I do hereby certify,,under the pains and penaltles ojperjury that tlie inforneation provided above is true and correct Si ature: � Qi�� Date: o� �� Ph #. Official use only. Do not write in thu area,to be con�pleted by city or town officiaL City or Town: Permit/License# Issuing Autharity(circle one): 1.Board of Health 2.Bnilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.maas.gov/dia