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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 D�c mber 16�20I¢. � Failure to do so will result in the retum of your a licaho" n ket. ESTABLISHMENT NAME: LOCATION ADDRESS: -�D p� t9t�+�'� TEL.#:Sd - MAILING ADDRESS: '►' - Q E-MAIL ADDRESS• i� I Qd- OWNER NAME: ' CORPORATION NAME APPLIC�LE : '; MANAGER'S NAME: TEL.#: � � � MAII,ING ADDRESS: � POOL CERTIF'ICATIONS: z o ;� The pool supervisor must be certified as a Pool Operator,as required by State 1aw. Please list the designated n � Pool Operator(s)and attach a copy of the certificadon to this form. � � �°�� 1. 2. m � �i Pool operators must list a minimum of two empioyees currently certified in standard First Aid and Community v d �":� Cardiopulmonary Resuscitadon(CPR),having one certified empioyee onpre mises at all times. Please list the --� v� � employees below and attach copies of their certificarions to this form.The Aeaith Department will not use past years'records. Yoa must provide new copies and maintaia a file at your place of business. 1. 2. 3. 4. �� FOOD PROTECTION MANAGERS-CERTIFICATIONS: 'M�� , Ali food service establishments are required to have at least one full-time employee who is certified as a Food �{�; , Pmtection 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 wili not ase past years'records. You must provide new copies and maintain a file at your establishment. � a „}� i. 2. � t�� PERSON IN CHARGE: "'` J Each food estabiishment must have at least one Person In Charge(PIC)on site during hours of operation. x ' 1. 2. i 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)(3)(a). Please attach ; copies of certification to this application. The Hes(th Department will not use past years'records. You must provide new copies and maintain a file at yonr establishmen� 1. 2. HEIMI.ICH 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 atl tirnes. Please list you�r employees trained in anti-chokuig procedures below and attach copies of employee certifications to this form. The Iiealth Department will not use past years'records. 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 REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PF.RMIT# �B S55 CABIN $55 MOTEL St10 lINN S55 CAMP S53 _SWIMM[NGPOOLSIIOea. ,�..ODGE S55 =T'RAILERPARK $105 _WHIRLPOOL SllOea FOOD SERV/CE• LICENSE REQUI1tED FEE PERMIT# LICENSE REQllIR£D FEE PERMI?# LICENSE REQUIItED FEE PERMIT�! 0.100 SEA'1'S 5125 _CONTIIVENTAI. E35 NON-PROFTT S30 >100 SEATS E200 _COMMON VIC. S60 —WHOLESALE S80 RETAIL SERVICE: —��•�TCHEN S80 LICENSE REQUIRED FEE PF.RMIT# LICENSB REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# <50sq ft. SSO >25 000sq ft. 5285 VENDING-FOOD S25 �'Q =�25>000sq.ft. S150 �?j �'RaZENDESSERT S40 ZTOBACCO $t]0 D NAME CHANGE: S15 AMOUNT DUE _ $ 2t�.Od *'+"�PLEASE TURN OVE12 AND COMPLETE OTAER SIDE OF FORM*�""* �a��,{5��3^�Z" I;� Fi�4�TP-�`3-�S�`�'-62- � I t � � , ADMINISTRATION ! Under Chapter 152,Section 25C,Subsecdon 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 COMPENSATTON 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 pernuts. 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 az►d short terra occupancy,ordinarily and customarily associateci with motel and hoteI use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty(30)days,aud 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 OPEI�IING:All swimming,wading and whirlpools which have baen closed for the season must be inspected by the Hea(th Department prior to opening. Contact the Heatth Department to schednle the inspeetion three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until tlie paol 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 iab,and submitted to the Heaith 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. , i FOOD SERVICE ' SEASONAL FOOD SERVICE OPENING: ' All food service establishments must be inspected by the Health Department prior to opening. Please contact the i 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 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.vazmouth.ma.us under Health Department, - Downloadabie 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 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 ofHealth ' OUTDOOR COOKING: ' Outdoor cooking,preparation,or dispiay of any food product by a retail or food seivice establishment is prol�ibited. NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY 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 REQ SITE PLAN. DATE: ��'! � SIGNATURE: /� , PRINT NAME&TITLE: � � O ��J' (/J�',r�� ' Rev.10/12/16 r � The Com�nonwealth of Massachuseits Department of Industrial Accidents Offue of Investigations ' 1 Cangress Stree�Suite 100 Boston,MA 02114-2017. www m�s�gov/dia Workers' Compens�tian Insurance Ai�edavit: General Businesses Analicant Information Please Print Le 'g�blv Business/Organization Name:;�C{s�� (,C7Y�y�� i A- �p� Owa"�E (�� Address: f�a - � - � cd �o� K�� l� � City/StatelZip:��C�'�.,�� ,� ��.6�� Phone#: ,.5�� Are yon an employer?Ch�k the appropriate bog: Bnsin Type(reqnired): 1.❑ I am a employer with � employees(full and! 5. �Retail or part-time).* 6. ❑RestaurantrBar/Eating Establishment 2•❑ I am a sole proprietor or partnership and have no �, [� Office and/or Sales(incl.reai estate,auto,etc.) ernployees working for me in any capacity. [No workers' comp.insw�ance required] $• ❑Non-profit � 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance required)* 11.Q Health Care 4.❑ We are a non-profct organization,staff�xi by volunteers, with no employees. [No workers' comp.insiu�ance req.] 12.�Other •Any applicant that cher.ks box#I must also fill out the section below showing Ybeir v�rodcers'oompensation policy informatia�. •"If the corpo�ate officers have exempud themselves,but the«wrrporation has other employees,a workers't�ompensation policy is required and such an organizatioa should checic box#1. I am an en�ployer that is provlding workers'r�mpeRs��rance for my employeeS. .Below is the pol�cy e'nfornratlun. Insurance Company Name: - 1 Insurer's Addr�ss: City/State/Zip: � //► ' q � A Policy#or Self-ins.Lic.#_� � �d �Q S�' ��C � �� Expiration Date: d r a r d�� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the irnposition of criminal penalties of a fine up to$I,500.00 and/or one-year irnprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up ta$250.00 a day against the violator. Be advise�that a copy of this statement may be forwarded ta the Office of Investigations af the DIA for insurance coverage verification. I do hereby certify,under the pains and penalt�es of perjary that the�nformat�on provided above is true and correc� �� D�� /�- /��-� � Fh #• r �l�- D 4ffi'cial use only. Do not write in this area,to be caompleted by c�ity or towri oJ�ciaL City or Town: PermitlLicense# Issuing Authority{circle one): 1.Board of Health 2.Baildiag Department 3.CitytTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phoue#: www.masss.govldia