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Home My WebLink AboutApplication and WC ESTABLISHMENT NAME: c� ' - tc��,c w�w.� ': � LOCATION ADDRESS: 1 � W � � T'EL.#: lS `'17 I'L 3 S ' MAILING ADDRESS: � '' E-MAIL ADDRESS: c, ' 'i►.� C(� • " . OWNER NAME: � �" ' CORPORATION NAME(IF APPLICABLE): � MANAGER'S NAME: M�tfL4Pt2C'�'�t(�6C�-`-� �AP�lO D�M��S�`/ TEL.#: �I �/-LI � MAILTNG ADDRESS: (60 W!Lf[r� RO �3 '��NZMdU�64�- �t�t— O�bd�( P�OL CERTIFICATIONS: �`�`�'��'��"�"' The pool supervisor must be certified as a Pool Operator,as required by State law. Plea list�Cd 1��e� Pool Operator(s)and attach a copy of the certification to this form. 1. `"''� 2. Pool operators must list a m ' of two employees currently certified in stan irst Aid and Community : Cardiopulmonary Resuscitation( having one certified employee an premises at ' es. Please list the employees below and attach copies of the� 'fications to this form.The Health Department t ii[ate past years' records. You must pravide new copies aintain a file at your place of busines �;;� O�� 1. 2. �. . ;�:�-y 3. 4. � FOOD PROTECTION MANAGERS-CERTIFICATION5: 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 HeaIth Department will not use past years'records. You must provide new copies and maintain a file�t your establishment. 1. �v 4�� "�1�1pS�� ' �'OIJI�C.I�—�WCU-t�JS 2. ��l�l� �I�� 1"J ' PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. � ' �� 2.��d� L.�1��!'� ALLERGEN CERTIFICATIONS: All food service establishmsnts are required to have at least one fu11-time employee who has Allergen certification, ' as defined in the State Sanitary Code for Food Service Establishments, l OS CMR 59Q.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 capies and maint�in a fde at your establishment. 1. ��(��;��t,P��I 2. tM �� c,=c+�� —� —�_ — 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-choking procedures below and attach copies of employee certifications ta this form. The Health Department will not use past years'records. Yau must provide new copies and maintain a file at your place of business. 1. D v tr� s��-( a. N+�v..a �I�u,o� p0 � 3. L� 4.�. �4 L� � Ol�v � RESTAURANT SEATING: TOTAL# �5 LODGWG: OFFICE USE ONLY g U b}-F��-r'j.�{,8 33—�' LIEENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B8cB $SS CABIN $55 MQTEL 5110 INN $55 CAMP $55 _SWIMMING P40L$1 l0ea. �T,ODGE �55 T'RAILERPARK $105 �WHIRL,POOL $110ea. FOOD SERVICE: �L CENSE RE UIItED FEE T# LICENSE REQUIRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# 0-100 SEA�S $125 ��7 CONTINENTAL S35 NON-PRO�IT $30 >100 SEATS �200 =COMMON VIC. $60 �(08 WHOLESALE S80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 ft. $285 VENUING-FOOD S25 {�3 35•pd �<25,000 sq.ft. $i50 #��36 �ROZEN�ESSERT �40 Tc)RACCn �110 , vt utty tt�cu�a vi yciiiu� w vycia�c a vu�iuo� ii a Yciavu vi wuiyu►ty uvv� u��uavc ta L.ci�iiia.a�c vi rvvinvi � Compensation Insurance. THE ATTACHED 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 CHECK APPROPRIATELY IF PAID: / YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hatel 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 occupartcy shall generally refer to continuaus 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, sha11 generally be considered Trans;ent. ' 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 schedule the inspection three(3) ciays priar 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: T'he water must be tested far pseudomonas,tatal 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 OPENING: Atl 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 ta the catered event. These forms can be obta.med at the He la th Department,or from the Tawn's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. � FRC)ZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result m the suspension or revacation of yaur Frozen Dessert Permit until the abave terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health. ; OUTDOOR COOKING: i Outdoor cooking,preparation,or display of any food product by a retail or food service estahlishment is prohibited. , � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN ' ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'TITTG, NEW � � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � � TO CO NCEMENT. RENOVATIONS MAY REQ SITE PLAN. T�ATF.• �� tJI�dI� CIC;NATTiRR• � �� -y� , t� ' The Commanwealth of Massach uset�s ��`� nt De nt o Industrial Accide s Fa� f Of,�ice of Investigations �N� �� 1 Congress Street,Suite 100 'I Boston,MA 02114-2017. www.mass.gov/dia Workers' Compensativn Insurance A.ffdavit: General Businesses AnAlicant Information Please Print Le�iblv Business/Organization Name: ��L� I L �I��l�� Address: �� '� tL� �� ' � City/Sta.te/Zip: w �, l�l�l Phone#: ��U�� 1 �'�� Are you an employer?Ch�k the appropriate bog: Business Type(required): 1.[�I am a employer with�_employees(full andl 5. ❑Retail or part-time).* 6. �esta.urantyBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �pff�and/or Sa1es(incl.real estate,auta,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 "Any applic�nt that chedcs box#I must also fill out the section below showing iheir workecs'compensatian policy infotmation. '"If the corporate officeis have exempted themselves,but the oorporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an ernployer that is provdding workers'compensation insurance for my employee� Below is the policy infonmatlon. Insurance Company Name: Insurer's Address• . City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaralion page(showing the policy nnm�r and e=piration date). Failure to secure covexage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . flne up to$1,SQ0.00 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 ma.y be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ' ,un th ains and penaltles of perjury that the informatian provided ve' true and correet Si J � Pn #: Sa�'��/� " 3 �c�� 7� - �� -!� S� Offictal use only. Do not write in this area,to be completed by city or town offuiaL City or Town: PermitlLicense# Issning Authority(circk one): 1.Board of Health 2.Bnilding Department 3.Ciiy/Town Clerk 4.Licensing Board 5.Selectmen's Of'lice 6.Othee Contact Person: Phoae#: www.mass.govldia