HomeMy WebLinkAboutApplication and WC � TOVdiV Or Y_�RMEC3iJT`gI BOARB(3�`�lEErIL.TH
APP�,T�ATI�l�f F�Td I.�C]ENSFfP�IZ�VII`T-2�17
, ` *Pl..ase complete furatz a:.d uttacr�all necessary�ocuments�ry Decembe�1�.lai6.
Failtar�;tc�d�sc�v'�1�.�esLxt in tr�e return of you.*appaication gackef.
ESTABLISHMENT NA�fE: � T • /
Lt�CATION ADDRESS: �3 tV�! e kTS . � �� oU / TEL.#: O �376'• ao�
MAILINGADDRESS: o7d f lO�/l � 4U D O� y
�-M��,�r�u�ss: � e li� �T j �H/� �"� a
OVw'1tiER NAME: f e Cy 0��/ �/��� � :
�:?:�_�OT�:ATION 14Tt��VSE�r�.�-.PF��E:,�A F}:
�.aNA��R�s�AM�.: r��� ��r � o Q.f EL.#: Gj .�a�%�ao�'
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P�OL GEI2TIFICATIONS:
T`h�gool supervisor m�nst be eert�fied as��'aol C3per�tor,as r�equireti by State law. Please list the designated
Pool Operator(s)and attach a eopy of the c�rtificatian to this iormT �
l. 2.
Foc��gerators must iist a n1in:.mczrn�i'ttiva�crspl�ye�s cutrently e�r�i�ied in s#andard Pirst Aid and�Commau�ity � � � 4 �
Cardiopulmonary Resuscitarian(CPR),na�rin�one certified employee an prernise�at ali tnnes. Please list the `p r a !:
employ�es below and attach cop+vs of th�ir ce�ifi��ticns to�hzs fa.m.'A'f�e�eal�h Y?�par�ment svill not ase past -.,� _..; i
yFar�'records. Yo�ra�rast�re�vide�ew�b�6es and�aa�t�in a fif�at your p4ace�f businz�s. i-;_ � �
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Ft�OD PROTECTION MANAGERS-CERTIFdCATIONS: '
a 31 food servic�esi3biish:-ryent�are rd.�c�wreci?o hA:re a:1��ast or,e fif?lPti:ne em�;toyee saho is�erti;ied as a Fc��d ���
I�raz�ction Manager,�s deFined an the Stzte Sanitary Code for Foad�ervice Establishments, l��G'_vIR�9G.�?i;G. �''�'�k'•�
Pleasr attach copies of certification to this a�plicatisrri. �`�e�Iealch I3ep�rt�en�wi1R uat aase gast y�ars'r�corsLe . `�
�''oa must provide naw eopiea amd�srintaar,a�le a#v��r estab3eshmo�nt. '°'�
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PEI2SON iltiT�HARG�: ; -�
Each food establishment:nust have aE iea�t ane Person In Charge(a'I�)or.site�ur:n��c�iss of operation.
�:
� 2.
ALLERGEN C:ERTI�ICA'TIONS: '
AII food service establishments are required to have at least one fuil-ti�ne employee who has Ailergen certification, '�
as defined in the State Sanitary Code for Foad Service Establishments,105 CMR 590.009(G)(3)(a). Please attach
copnes of certification to this application. The�ealth Department ve iil not use past years'reeords. You must
provide new copies and maintain a fite at your establis6ment. '
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HETMLICH CER'I"IFICA"TIONS: '
Ail faod service establishm�nts with 25 seats or more must have at teasi one employee trained in the Heimtich
I�rl�aze=sv�;.on ehe�remisvs aE ali t�mes. Please list your employe�s trair�ed ir anti-e�oki.*�g procetlures balow a.*�d
attac?�copies of employee csrtif cations�o:his form. "�he Hsalth Deq�arta�ent will not�se pa�t year�`recards.
Yau must provide new copies a�d�aintasrs a�le�t your place af Dusiness.
1.�.��� _,_ 2.
3. 4. � ��
k�,5'l.�iUIZANT�`EATIivG': T�Y i AL#�._..�.
t3��1C�iISE ONL�'
�.t��r�tt��: �
L;GEt1SE REQU[R,.0 FEE PERrvfIT ii LiCEt:SE REl�UP.�2E�3 F}:£ PEItP�:I;t� LICENSE REQUIRI:D F�E PERIvi:T#
_ c34::; �55 C.5';I� $55 IvfOTEL �110
-�'.;h �55 vC�ll,l� ¢55 ---- —SWIMMTNG POOL$110eav __._
_LC;DGE $55 �—� __-,fr"�.hiiERPAt7K $105 ���� �WHIR[.POQL $IIOea
F(DbD SERViC£:
L3�.�,NSE REQUIRED FEE PERMIT# LSCEitiSE RE(�UIR�;D �EF; P�F Rii'f ik L?CENSE REQtiIRE'il F$E FERt;i"i l.'
_C-�eJSEArS $125 _.CCNTIN�':v�f�i ��S NON-?'ROFI; $30
_>lOQ SEATS a2�'v .^,t)M3�Ctt VIC. $&C� ------ —NFiOI.ESALE $8it --_.___
---�-- -- --------
-�FrSID.i{ITf.HEN 560 ___�_
S��'TAid:SE1tVICE: --
LIC::NSE REQUTRED FEE PERi�'�I':"7 �!CL'vSL ICat;UfR1:D Fr.E °E)2N�tT« L.IC��`SE;tEQ'v'FREil FBE �ERMtf�
<50 .8. S50 25,{iz�tf o.fi. �*g5 .----.--- __b'ENDI3Vf,-FOOD S25
_..__. __.________
�F25: �sy.ft. 5I50 �-�� �rRJ2F•,N!):SS�2z :e+r) ___._.w_ _TU8ACC0 $!10 – --
NAME CHAlY�E: $SS ���. A.�OUTN�DUE = $ ��O� O�J
'*•"#pLEASE`i'liivY US'E�2 AlYD C��fPLETE O"SF3ER SdllE aF FdRM°Ri°"
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,
A13MINISTRATION
Under Chapter 152,Section 25C,Su'�section b,[h;,Town cf Yannoutta is now required to hold issuance or renewal '
of`any license ar permit to operate a business if a person or company d�aes not have a Certificate of Worker's '
Comnensation Insurance. THE ATTAC.HED S`Y'ATE WQI2KF.R'S COIV�ENSATTON INS€JRANC� :
AFFI�?A�IT 1VIUST BE COlVIPI.ET�D Ai`�I3 SIGNEI),�R
CEKT.C1P INSURANCE A'TTACHEi�
OR �
WORK�R'S COIvIP.AFF`DAVIT SIGNED AivD ATTACHED
Tcv�n cf Yarmouth taxes an�Yiens mzast u�,pa.�d�rior to renewal or isss�..�ce of yTai:z�permits. PLBASE CI�F,C�
APPROPRIATELY IF PAYf�: �/
'YES NO
MOTELS AND OTI�ER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of MateP or Hotel use,Transient occupancy shatI be
Iimited to ihe temporary and shart term occupan;;y,ardinarily an�i customarily associated��vith motel and hotel use. '
Tra.-�sient occtipants must have and be abPe ta deznanstrate thai they rnainFain a principat place of residence �
rts�.�here.Tsansi�nt�c�upancy shalt�e�e.�sl;refer t�coniinaaous c�ectipanc�y of�o��aF e t1�an thirty(30}days,aud
a�s a��z•e��;�ite o2 aaoi:�zore fhar::iinety(9t�)4ays w�i::in any six(6)month periad. iJse of a guest unat as a residea:ce or
dwelling unit shall nat 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 rmended,shaU generally be considered Transient.
POOLS ',
P�OL{3PENING:Ail swi�ming,wacl3ng and wivrinools which have been etosed for ihe season must be inspected
by tite 1-IealYh Department prior to apening. Contact the 1FIeatth Departznent to scl�eeiuie t9te inspection thrce(3}
alays�rior to opening.PLBASE NOTE:�eopPe are NOT'allowed to sit in the pooi area until the pool has been
ii�spected and opened. '
F�3��1,Vi'A'�'ER T�ST�itiG: "F'k-:e water must be tested for pseudomanas,tvtal cotifarm and siandard plate count
by a S4ate certified lab,and submitted ta the Health I3epartment three(s)days prior to apening,and quarterly
thereac''ter.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD S�RVICE
SEASONAL FOOD SERVICE OPENINGc '
All fc�od s�rvice establishments must be=,nspect�d by the Heaith Department prior to opening. Please contact the
3-�e:3I�h Ue�nartment to schedule the inspectien three(3)days prior�o a�e�sing.
CA'!'�RiNG POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing ihe
required Temporary Food Service Applicatian form 72 hours prior to the catered event. 'd'hese forms can be
abtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Deparhnent,
I?ownloadab?e Forms.
�'�s�'��I`���SSEI�'i'S�
��rozen desserts must be tested by a State c;.rtifaed lab prior to opening ar�d monthly thereafter,v�ith sample resutts
submit�ed to tiie Health De��ttmen'r. Failure to do so wili result:r:t:1e suspensior oz revocarion of yaur Frozen
�Jessert Permit until the abave terms have been znet.
()UT���F CAI+�S.
Outside ca.fes(i.e.,ouYdoor seating with waiter/wa.ih�ess servace),must have prior approval from the Board of Health.
dtiTAO�I2 COOKING:
Gutdoar coolcing,prepazation,or display c�z any iood product by a retazl or food service establ;shment is prohibited.
� l�t3TYCE:Pemuts run anni:atl�from Jan�<zry I te i�eceniber 31. IT dS Yt3U'i2�2ESPONSiBII.i'TY TO RE t tJRN
' THE COMPLETE�RENEWAL APF'LI�A�IGN(S)AND I�.QUIItE9?�'EE(S)BY DECEMBER 16,2016.
ALL RE?�10VATIONS TO ANY �'OOD ESTA�LISHMENT, MOTEL OR POOL (i.e., PAINTING, 1VEVV �
� EQUIPMENT,ETC.),MUST BE REPORTEI7"I'O AND APPR VED BY THE BO F HEALTH PRIOR '
?'c�C�MM�NCEMENT. IZENOVATIONS MAY REQil A SI�"�FLAN. ..
Br'�,"1'E: /Q�l�I/�� SIGNATL'RE; ��
PxirrT r���M�&r�rr,�:--/,/�`�i`��C__ ll�J � U� cP� eJ'
Rer.10/1:/t6
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� The C'ammo�xwealth ofMassachusett�
Depart�raent of�ndustria�Accidents
Office of Ir�vestigations
� 1 Congress St�eet,Suit��00
��sta�,11�G4 �D21��-2�I7
www.r�ass.gav/ilia
�Vorkers' �ompensatic��I�su�an�e A,#�ic�avit: Geaerai�usinesses
A�t�lic�a�t I�formation Piease Print Le�iblv
��asir�e�sh�rganization Name: �U� l ����,t�� �I��,�' �� �
�.����5�: r.� 1,c�1//6 �v J ,� > yf1 ,� �� lr�f� ��/�r �-1f� �� �7�
cB��s��Iz��: pno�e�: ��� � �.3�a - oa o 7 '
Ar��.a�emplmyer?Check the appropriate�x: Busine�Type(required):
1. I am a employer with employees(fult and/ 5• ���Retail ,
� c�part-t��u).* C. � &�estauru?�t��rfE�ting Estabdishmen� �
� 2.�i` g��so►�paaprietor o;partr_ersrig��rtd havz nc� 7. � ���ce andlor Saies(inct.reai estate,auto,etc.j �
employees working for me in any capacity. ,
[No w��ikers' comp.insurance required] �. ❑Non-�roftt ,
� �.❑ We are a corporation and its officers have exercised � 9. ❑ Entertainment ',
their right af exempti�n per c. 152,§1(4 j,and vra have � 10.� Nanufacturing t
= no employees. [lvo workers' comp.insurance required]*
I 1.[�Health Care �
_; �e� �ds are a non-profit organization,staffed by volunteers, �
; �a�th n�empioyees. [No workers' comp.insurance req.] 1�.� Gt�e� �
�:g.as�•�pplicant that checi�s box#1 must also fill out the section below sliowing theu workers'campensation policy information.
"*If the ccrporate�,.*fiaess nave exempted thcroselves,but the corporatifln has o:her employees,a workers'compensntion poIicy is required and such an
ar�i�ir�,sY-�ou��cheek box#i.
I ar�a��a errt1vloyer that is praviding workers'com�re�s�tion snst�ranre.for my eanaplo,ye�s. Below i�the policy informatann.
Insurance Company Name: �� /e��`�-�� /������� � � �y�0 U� .L/?� .
��s�����s A���Ss: � � � � � a� �'�'� a a� — ��a �-
City/SYate/zip:_ ���n ��� � / /�� D�o? ��
�'c�acy#or Self-ins.Lic.# ������0.3/��9�/ � ._Expiration Date:_ ��� /"? �� �
�,�ch a c��ay af t���vc�r�ers'�om�nsation pal��y d�larstioe page{shooving����licy number and expirAtioa date).
F�.:!ur;,tc�secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
�in�up to$1,SOQ.O£D�.tid/ar one-yeaz imprisonment,as welt as civil penalties in the for�a of a STd��W�RK UI�ER ar�d a ri��
c�f up�t��25�.�v a�a�a�ai�st ta p violator. �c aa.v:se��nat�vcspy c�f t�-aa�sta`�ar��#�n_ay b���rwarded��,th���Mc�cf
Investigations of the DIA for insurance coverage�er�ficaron.
I do hereby certify nder the pa' and p lties of perjury t�aat t�ae information provided a6ove is true and correct.
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S: a�re; I)ate:
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�'' t�+f}`r'eirrf rsse�only. �o not w�ite in this�rea,ta be ce� l�ted by city or taw�a„�`,�cia�
Cit�or'i'ow�n: �err�att�.�cense# �
. �.�s€ain�A�tharity(circle o�e): �
� �.�sas��d af�Ieaitl� 2,Building Begartmen� 3.�ityfT�wn C��rk �.L.ice�sia►g Board 5.Selectmen's��ce �
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i� C`���act�erscsn: ��v�v�: ��
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