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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 December 16 2016. Failure to do so will result in the return of your applicat�on pac et. ESTABLISHMENT NAME: � • LOCATIONADDRESS: /oa /�i�A�'�1.��tvoD��aZC TEL.#: ,s'1�G+� L� 2 -��9 MAILING ADDRESS: , E-MAIL ADDRESS: Q�a�s re, - C•n'� OWNER NAME: CORPORATION NAME APPLICABLE): MANAGER'S NAME: GC G� ¢.�F TEL.#: - G.?� �`I MAILING ADDRESS: c o� r' 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. i. �,A��c�s G'v�t:iS a. ��r,�, ��ra � _ ;,%. Pool operators must list a minunum of two employees currently certified in standard First Aid and Community f=' (� ��, 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. ��-�tt�P C.'vaa�i.f' 2. �� [`�e�./J,n�,t+D- � _`� g"�? 3. 4. � s � 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 a file at your establishment. .._�' 1. J j,�hrtf /� O/�� 2. , . �' � � '��. � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �� _� 1. �D � r I r , 2. I�Yr�� l �J( I'�� T �� ALLERGENCERTIFICATIONS: ��„• All food service establishments are required to have at least one full-time employee who has Allergen certification, L as defined in the State Sanitary Code for Food Service Bstablishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicarion. The Heaith Department will not use past years'records. You must provide new copies aad maintain a file at your establishment. �. ,��fa� 1� s� P a! ; 2. t�b r( �C��l s.�o�� ,/� ' 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 a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificarions to this form. The Health Department wiil not use past years'records. You must provide new copies and maintain a file at your place of 6usiness. 1. �El� ��' 2. i�Yahl _ IIvDaNi 3. �� nr vi✓ 4. KLrL. RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY (�](jpt}3P-lS-(0�-02 L[CENSE REQUIRED FEE PERM[T N LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# a�B sss cnanv $ss o�►. s>>o �io++F•tS-lo`t4�0-2- —INN S55 —CAMP $55 �WIMMINGPOOLSIlOea�3 �,ODGE S55 =TRAILER PARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE�UIRED FEE PERMIT N 0-100 SEA't'S 5125 CONTINENTAI, S35 NON PRO IT S30 �100 SEATS 5200 �t� ZCOMMON VIC. S60 �g �HSID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N <50sq R S50 >25,000 sq.R �285 VENDING-FOOD S25 =<25,OOOsq.ft. $150 =FROZENDESSERT $40 =TOBACCO $110 NAME CHANGE: E15 AMOUNT DUE _ $ 370.�U **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** � , ADMIrTISTRATION 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 IN$URANCE AFFIDAVTT 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 v 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)8ays,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 Deparhnent to schedule the inspection three(3) days prior to opening.PLEASE NOT'E: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 tl�ce 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 opemng. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Apptication 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.yannouth.ma.us under Heaith 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 Hea3th Departrnent. Failure to do so will result in the suspension or revo�ation af your Frozen Dessert Pertnit 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 establishment is prohibited. i NOTICE:Pernuts 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 I EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I TO COMMENCEMENT. RENOVATIONS MAY`i��A STI' PLAN. DATE: �d'.��-1d�C SIGNATURE: ' PRINT NAME&TITLE: Sov��e Q�►! �I�4 Ala�/N;� �/�Q s�C��I; � tu�.�a�vie � � � � � The Commonwealth of Massachusetts Department of Industrial Accidents O�ce ojlnvestigations � 1 Congress Street,Suite 100 Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensation Insurance�davit: General Businesses AuAlicant Information Please Print Le�iblv Business/Organization Name:�H i2l�i 1�,��Q.,t.9do 1��,�' G�A-� Address: o ' City/State/Zip: d�� c�Q-�I�� hone#: �� ` �G�'- 9�� / Are you an employer?Check the appropriate bo$: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-rime).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole pmprietor or partnership and have no �, � Office and/or Sa1es(incl.real estaxe,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 requiredJ* i l.�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 their workers'compensarion policy information. *'If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an oiganization should chedc box#1. I am an employer that is provdding workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: /`��,L A��!?'1 L ��d/i-!�� w �� Insurer's Address: A�2�ca r�/ .S/ City/State/Zip: /30�o.-� �l,a o z��y� y?2/ Policy#or Self-ins.Lic.# lNGt�o /�v�3 0�d 1 Expiration Date: /��-u' Z�� Attach a copy of the workers'compensation policy declaration page(showing the policy number and egpirntion 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 violxtor. 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 certi , nder the pains and penalttes oJperjury that the information provided above is true and correct. i ��— Da /�'31 ��L Phone#L s6gf 3G1, �s%,�� Official use only. Do not write dn th�s area,to be completed by city or fown ojfuiaL 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