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Home My WebLink AboutApplication and WC i I ' �' TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERNIIT-2017 � *Please complete form and attach all necessary documents by December 16i 2016. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: ' 1 T • 193 / �'"pdUCko�-> L-AE�c-TION ADDRESS:c�� o,•Psr I?d� S w�/mo��h MA pzla(�/c TEL.#• S�C$ 32C 3�� ,ar , MAILING ADDRESS: �Ch E-MAILADDRESS:�Gj� �r.�/��(� ('��l,�C�,C� .7e 1— OWNER NAME: Su�n D 1�� i Or� CORPORATION NAME(IF APPLICAB E): MANAGER'S NAME: Su I r'�� TEL.#: � /S/ MAII..ING ADDRESS:07(0 ) � 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. 1. 2, Pool operators must list a minimum of two employees currendy certified in standard First Aid and Communiry 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. FOOD PROTECTTON 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. y ., � , Please attach copies of certification to this application. The Health Department will not use past years'records. � r�� You must provide new copies and maintain a file at your establishment. �=� � �. `�°�,csc� P, ,�_>� z. o c� � rn '� PERSON IN CHARGE: -D �, iTi Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. � � v 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments aze 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. �'`''��"�` � S 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-choinng procedures below and #i��'` attach copies of employee certifications to t1�is form. The Health Department will not use past years'records. �-��t You must provide new copies and maintain a tile at your place of business. 1. 2, 3. 4, RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTI'# LICENSE REQUIRED FEE PERMIT# �B S55 CABIN $55 MOTEL $110 E55 SWIMMING POOL$I IOea. _•��6 S55 =TRA LI ER PARK 5105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRfiD FEE PJ�R�M�[T,,#,�� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��100 EATS 5200 'P`�-F-'�J _COIvIIvIONNTAL S�3o5 —WHOLE3ALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT p LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq ft. $50 >25,000 sq.ft. 5285 VENDING-FOOD a25 _<25,000 sq.ft. 5150 _FROZEN DESSERT$40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ � �2e�,�>t'� '�**"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** �d��( / T 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION 1NSURANCE 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 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 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 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 Hea1th 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 standazd 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 Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yazmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly+.hereafter,with sample results submitted to the Health Departrnent. Failure to do so will result in the suspension or revocafion of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: 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 RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQLTIRED 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 AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA A SIT'E PL DATE: // SIGNATU : ` PRINT NAME&TITL • ; / e ; ', i Rev.10/t2/16 � The Commonwealth ofMassachuseits Department oflndustrialAccidents Uffice of Investigations ' 1 Congress Stree�Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Leably Business/Organization Name: W i cke� UVQc_��tJ� Address: �l� �s��/� �_�� City/State/Zip: oZ� � � � �S ,�j ,� � Phone#: j�_ � , T• Are you an employer?Check the appropriate bog: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. Reta'1 2.�art-time).* 6. �urantBar/Eating Establishment 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 aze 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.[]Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.� Other 'Any applicant that checks box#1 must also fill out the section below showing the'v workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. Iam an employer that rsproviding workers'compensation insurance for my employees Below is thepolicy information. Insurance Company Name: Insurer's Address: City/Sta.te/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration 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 Office of Investigations of the�DIA for insurance coverage verification. I do hereby certi ,under the pains an p alties ojperjury that the information provided above is true and correc�t. .-� �----�. Si a F e: " � <�""�._.Q..� Date: l �D / / Phone#: P�� 7 fp S Official use only. Do not write 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