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Home My WebLink AboutApplication and WC e = , I� � TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE/PERMIT-2017 I #Please complete form and attach ali necessary documents by December 16 2016. , Failure to do so wiil result in the retum of your applicaUon pac et. I ESTABLISHMENT NAME:-tata_ fiard e,r►s Pae r�c�o,d-�w�. 1..� TAX ID: O •o�(07 fo d 10 C— LOCATION ADDRESS:/B ka+hw�n M<<k�l Rd �u ar ar�rW► TEL.#: sog��,a a'�8b = �.. � MAILING ADDRESS: saw�-` � �. m E-MAIL ADDRESS: -F1n¢[�p�d.o_n s@ Ver�zan.ra.�t' � �"' � OWNER NAME: _ � CORPORAT'ION NAME(IF APPLICABLE):j{��,�{p��u,t►a•n "-F4�e. E�cn�r�o„t" r� '� MANAGER'S NAME: Sulie SK�c.Ws TEL.#:�7y'7��cS� �'� -:; � MAILING ADDRESS: :-� '' � .:-� � POOL CERT'IFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated Pool Operator(s)and attach a copy of the certification to this form. 1._ '�i,�.c.C�od�1z�1 °� • 2. Pool operators must list a minimum of two employees currently certified in standazd 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 at your place of business. 1. 2. ' 3. 4. ,�:R ' �� n i Q ,z FOOD PROTECTION MANAGERS-CERTIFICATIONS: ' Ali food service establishments are required to have at least one fixll-time employee who is certified as a Food � Protection Manager,as defined in the State Sanitary Code for Food Service Estabtishments, 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 m$intain a file at your establishment. � -: - �? 1. 2. . ;�.,;� PERSON IN CHARGE: �` Each food establishment must have at least one Person In Charge(PIC)on site during hours of operarion. 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)(3xa). 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. i. 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 empioyees trained in anti-choking procedures below and attach copies of employee certificarions 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# LICENSE REQUIRED FEE PERMIT# BBcB $55 CABIN S55 M07'EL $110 Q _IT1T1 S55 —CAMP S55 =SWIMMING POOL S110ea�V _LODGE $55 _TRAILER PARK 5105 _WHIRLPOOL S]l0ea FOOD SERVICE: L[CENSE REQ UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT k _0-100 SEATS S123 _CONTINENTAL S35 NON-PRO�IT S30 >I00 SEATS 5200 COMMON VIC. S60 WHOLESALE S80 —RESCD.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRF,D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25,000sq ft. T285 VENDING-FOOD S25 =<25,000 sq.R. 5150 =FROZEN DESSERT S40 —TOBACCO 5110 IVAME CHANGE: S15 AMOiJNT DUE _ � JIO.O� •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'*"** do+�sP•t5-�22Y—aZ r 1 � t , ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Cerkificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATTON INSURANCE AFF'IDAVTT 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 Hote1 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 genecally 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)montfi period. Use o�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 swimtning,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 pseudoznonas,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. 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 Yazmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Appiication form 72 hours prior to the catered event. Tliese forms can be obtained at the Health 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 thereafter,with sample results submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Fmzen 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. 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 RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � ; EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE$OARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A ITE PLAN. DAT'E: (1�1I1�O SIGNATURE: PRINT NAME&TITLE: � J��—S~� Rev.10/l2/16 � ; !� The Commonwealth of Massachusetts Department of Industrial Accidents Offue of Investigations � 1 Congress Street,Suite 100 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insnrance Affidavit: General Businesses Avalicant Information Please Print Le�ibly Business/Organization Name: `�"�e_ ��A.�,,,n �s�u.•-� ��-- Address: �� kt��,� w�1�� City/State/Zip: dvr +�✓k 0-�.t,�s Phone#: S� s 3�2 2�► 8� Are you an employer?Check the appropriate boz: Basiness Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-rime).* 6. � Rest�,utant�ar/Eating Establishm�nt 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 �I�U1v�.g�Q,� �2 s o�- 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]* I 1.Q Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.[] Other •Any applicaut that chedcs box#1 must also fill out the section below showing tbeir Wrorkets'compensation policy information. **If the corporate of6cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should chedc box#1. I am an employer that is prov8ding workers'compensatlon�tnsrtrance for my employees Below is the policy information. Insurance Company Name: Insurer'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 expiration 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-yeaz 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 Investigations of the DIA for insiu�ance coverage verification. I do kereby certi ,under the ains and pena[ties of perjury that the information provided above is true and correct Si ature: � Date: 11- !�l Phone#• 8 3b2 Z�K(p Official use only. Do not wrrte in this area,to be completed by city or town offuiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia