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Home My WebLink AboutApplication and WCr j^� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 � "' *Please complete form and attach all necessary documents by December l6 2016. �'�. - Failure to do so will result in the return of your application pac et. ESTABLISHMENTNAME:,�VI/9�2�(.[,Ei2t� E. S'm,4t� t2ir1.su�Foo L TAX ID: LOCATION ADDRESS: �/�/0 ih6l:�itJ S CPlouJt"LC _/1,� �tl.,/��tcur�l TEL.#: S�S'-773r'--'79 7(�, ' MAILING ADDRESS: S AnaE E-MAILADDRESS: Ou1�RSQ@ u [cc�Te✓ta./ K�2 m� u� OWNER NAME: (��1uiS �/.t,2�xo,,�r+l +�c,s-,oYu.i� scK�at tJi s7�tc,T CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME:__ e6 u �au�t�2S TEL.#: 5�0�-�qp�7�o0 MAILING ADDRESS: a9�'c S`n�4-riQ.l3 il,le' �. r1it,2awu,ri�. .vtil- 01G�gf 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. 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 empioyee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Healt6 Department will not use past years'records. You must provide new copies and maintain a file at your ptace of business. 1. 2. �zn v�: � 3. 4. D `�: �3 � � _ � FOOD PROTECTION MANAGERS-CERTIFICATIONS: p ' � All food service establishments aze 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 a�le at your establishment. ; 1. e✓�'7?f9� /cc.c�J-i.�0 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. �A17�-it ,�f'�iNb 2. ALLERGEN CERTIFICATTONS: 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 Estabiishments,105 CMR 590.009(G}(3)(a). Please attach copies of certification to this application. T6e Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. � l. ��.�'r �-(=�✓✓G 2. HEIMLICH CERT'IFICATIONS: 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. T6e Healt6 Department will not use past years'records. You must provide new copies and maintain a file$t your place of business. 1.__ �cTt1�C- Kc�`.tj0 2. 3. 4. RESTAURANT SEATING: TOTAL# �oncuvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRF.D FEE PERMIT tl _B&B S55 CABIN $55 MOTEL $110 _(NN S55 CAMP S55 —SWIMMINGPOOLSIIOea. _LODGE $55 _TRAILERPARK 5105 WHIRLPOOL SIIOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICF.NSE REQUIRED FGE PERMIT# LICENSE REQUIRED FEE P RMIT 0.100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 �1Zfe? >IOOSEATS $200 _COMMONVIC. $60 TWHOLESALE S80 �RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SO sq.ft. �50 >25,000sq 8. $285 VENDING-FOOD S25 i<25,000 sq.ft. 5150 =FROZEN DESSGRT $40 =TOBACCO $110 NAMECHANGE: SIS AMOUNT DUE _ $ W��V� •'***PL�ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****" P�otl-F-IS-fB�}C -d2 T ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yacmouth 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 COMPENSAT'ION INSURANCE 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 shail 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 sc6edule the inspection three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. I 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 or covered within seven(7)days of closing. FOOD SERVICE SEAS�NAL 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 Departrnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. T'hese 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 vpening and monthly thereafter,with sampie results submitted to the Health Department. Failure to do so wiil 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. 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 RESPONSIBILITI'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 i ' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ! TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL N. DATE: I/ll�(o SIGNATURE: �� : PRINT NAME&TITLE: �d�l.Ut;� G1u/�"K s �S t�.�/�S 1� Rev.10/12l16 � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 �ostora,M�4 O�ll4-ZOI7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print Le�iblv Business/Organization Name: DENNIS-YARMOUTH BEGIONAL SCHOOL DISTRICT Address: 296 STATION AVENUE City/State/Zip: SOUTH YARMOUTH, MA. 02664 Phone#: 508-398-7600 Are you an employer?Check the appropriate boz: Business Type(required): 1.� 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] 8• ❑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 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 EDUCATION "`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. *"If tbe corpornte officeis have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such aa organization should check box#L I am an employer ihat is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: COOK F� COMPANY Insurer's Address: 1025 PLAIN STREET, PO BOX 1068, _ _ __ City/State/Zip: �SHFIELD MA. 02050-0009 Policy#or Self-ins. Lic.# EWC006911 Expiration Date: 6/30/2D17 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 a 152 can lead to the imposition of criminal penalties of a fcne up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP VJORK 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 certify,under the nd penalties of perjury that the information provided above is true and correct. Si ature: Date: �� I / Phone#: -3�i?�~ 7Gav Official use only. Do not write in this area,to be compteted by city or town officiaL City or Town: PermitJLicense# 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�ass.gov/dia