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Home My WebLink AboutApplication and WC, � �^� TOWN OF YARMOUTA BOARD OF HEALTH �� -�� ` APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach a11 necessary documents by December l6.2016. Failure to do so will result in the return of your application packet. ESTABLISF�vfEEN'TNAME: JYIM�r4C+tfc"BEmi�r716 S�Cc'frao� TAX ro• ; � LOCATTON ADDRESS:1{AD H7Cre�;uS Ci2ouIFJ-L RD uJ �,�t,z,usu7Ntjl�r�3TEL#• 3�b'-7�1�-7t 7�i ' MAILING ADDRESS: sAmE E-MAIL ADDRESS: PdW�YS 2� c�v—(le9 ltrrta./.K/2. /yta,u.5 OWNERNAME:__ �'71J�vis �/�TN ��o`u.�. SGlfJGL �Jisrn�cT- CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: �2uo�uC"y POw�'�ZS TEL.#: 3"dt?� 39F��7fo0a MAiLING ADDRESS:��"t� STi9-T�e,v th�E. 5, t/�hL.r�.c7�1 eaGG� ,� POOL CERTIFICATIONS: 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. l. 2. 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 � �� years'records. You must provide new copies and maintain a file at your place of business. y �`9 L 2. _ :~ i"�'1 3. 4. � _ � m - � �' � �_�a ---t ��: FOOD PROTECTI R - R I � ON MANAGE S CE TIFICAT ONS: All food service establishments are required tv,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 ttus application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment 1. /�/�K�Z �i sceGL�b 2. . PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. �,q-�EL. �i s�?=-C.-r D 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one ful!-time employee who has Allergen certification, as definedin the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicarion. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. � 1. �� ll�s GP.�.(,t 0 2. � � �� HEIMLICH CERTTFICATIONS: 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 nat use past years'records. You must provide new copies and maintain a file at your place of business. 1. i�e.�-Z V 1 S��.s U 2 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGIlVG: bICENSE REQIlIRED FEE PERMIT it LICENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN S55 MOTEL S110 INN $55 CAMP $55 _SWIMMING POOL$1 IOea. _LODGE a55 _7'RAILERPARK $105 WHIRLPOOL SilOea. FOOD SERVICE: . I.ICENSE REQtJIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT$68 0.100SEATS $125 _CONTINENTAL a35 /NON-PR9FIT- S30 7KJ >t00 SEATS 5200 _COMMON VIC. $60 WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 UCENSE REQUIItED FEE PERM[T# LICENSE REQUIRED FEE PERN(IT# LICENSE REQUIRED F6E PERMIT# _<50 sq.ft. $50 >25,000 sq:ft. $285 Y£NDING-FOOD �25 ' _<25,000 sq.R S150 =FROZEN DESSERT$4Q _TOBACCO $110 • NAME CHANGE: $15 AMOLTNT DITE _. $ W�'I V li� *****PLEASE TURN OVER AND�QMPLETE OTHER SIDE OF FORM*�«*" �/�_� ^n � � � � " . I��V v�� , � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesiigations I Congress Street, Suite 100 Boston,MA O�Il4-ZOl7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant 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 bog: 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 andlor Sa1es(incl.real estate,suto,etc.} employees working for me in any capacity. [No workers' comp. insurance required] $• ❑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.� Hea1th 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 tr�e corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is requ'ved end such an organization should check box#1. I am an employer that 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 1058, City/State/Zip: MARSHFIELD, MA. 02050-0009 Policy#or Self-ins.Lic.# EWC006911 Expiration Date: 6/30/2017 Attach a copy of the workers' compensation policy decfarafion page(showing the policy namber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL a 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 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the ' andpenalties ofperJury that the information provided above is true and correct. Si ature: Date: / ! Phone#: SZJ�'"35�- 7(o a Official use only. Do not write in thu area,to be completed by city or town officiaL City or Town: PermiE/License# Issuing Authority(circle one): l.Board of Health 2.Building Department 3.City/Town Clerk 4.Licens'rng Board 5.Selectmen's Office 6.Other Gontact Person: Phone#: www.mass.gov/dia , � 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 A1'TACHED STATE WORKER'S COMPENSATION 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 CHBCK APPROPWATELY 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 sc6edule 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 or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENWG: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Depaztment 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. These 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 Heaith 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. i OUTDOOR COOKING: i Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY 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 AND APPROVED BY THE BOARD OF HEALTH PRIOR , TO COMMENCEMENT. RENOVATIONS MAY RE A SITE AN. DATE: /l/J(�Co SIGNAT'URE: ,fJ PRINT NAME&TITLE: Ud 1��'�' F�S1� �D 2 S� Rev.10/12/l6