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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH ��"�� °� `� APPLICATION FOR LICENSE I 2 O , �� ""� * Please complete form and attach all necess t "" ber Ib-201'� � Failure to do so will result in the ret ' f y '��p ' t " cke . , �!�a�.T� ��: ESTABLISHMENT NAME: B�(�-[8�1��"lL/� TAX ID•�- � ; LOCATION ADDRESS: ��-1aC A�cr �1� T y�evr►a�r� TEL.#: 2�0-f.oa2� i MAILING ADDRESS: 1�3�Z. 1-t�•�� 21�D I ; ', E-MAIL ADDRESS: I�Y�I`GG� l.k.� ;TaI�t�1 Son a �SL •Cora OWNERNAME: I�f.(A�M1�C�f JCSIrtiI`Gs�Sr�L CORPORATION NAME (IF APPLICABLE):�6��P.�GS`l�( � S��S i MANAGER'S NAME: nS�r�c.y �o�r� � - _ : - TEL.#:5�_2�—t�f�j 1 MAILING ADDRES S: �5'2 Ci�22� ✓..l�l� �.v c�'T �s�2✓hc7�-t-�i V►'�� a 2.��3 i ' 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 copy of the certification to this form. 1. t\I�CY`� 2. � Pool operators must list a minimum of two em lo ees currentl certified in standard First Aid and Communi � P Y Y ty � 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. �� 2. 3. 4. i I 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.�� 2. , PERSONIN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1, II�,(-� 2 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 Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. r�cl� 2. 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 af 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 not use past years' records. You must provide new copies and maintain a file at your place of business. 1:_��1� 2. 3. 4_ RESTAURANT SEATING: TOTAL# -- -- -- _— -- - - - - -- . - -----_ __--_ __ � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. =LODGE $55 � =TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,OOOsq.ft. $150 =FROZENDESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ SS�vv *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �0�L-/S�S I��-0"Z, R _ 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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE ATFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE 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 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)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 schedule 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 ar 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 opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department 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.yarmouth.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 Health 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 CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: ' Outdoor cooking,preparation,or display of any foQd product by a retail or food service establishment is prohibited. : t . NOTICE: Permits run annually from January"I to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APP�,ICATION(S)AND REQUIRED FEE(S) BY DECEMBER 16, 2016. ' ' ALL RENOVATIONS TO AI�Y 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. RENOVAT.IONS MAY REQUIRE A SITE PLAN. DATE: � G ��SIGNATURE; �I� FRINT NAME & TITLE: f�.I�1'�1��- at,t �i2� � ' Rev. 10/12/16 , � The Conunonwealth of Massachusetts Department`of Indrfstrial Accide�ts Office of Investigations ' X Congress Stree�Suite 140 . Bastnn,MA 42114 2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: General Bnsinesses Aaalicant Information Please Print Le�iblv Business/Organization Name:�� [��-�/�i.�� Address: �l � f�`�.r=�?,-�--� ��. � � � � City/State/Zip:��n(��-F-/ ►ry�t�,p��o7� Phone#: Are yoa an employer?C6eck tLe appropriate bog: Business Type(reqnired): 1.❑ I am a employer with employees(full and/ 5. ❑Retail ; or part-time).* 6. ❑ RestaurantrBaz/Eating Establishment ' 2.[�-I am a sole pmprietor or partnership and have no �, � Office and/or Sales(incl.reaI estate,auto,etc.) employees working for me in any capacity. �' [No workers' comp.inswance r�uired] 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 10.0 Manufacturing no employees. [No workers' comp.insurance required]* 11.Q Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.�Other ( t��E 'AnY e�licant thst checks box#i must atso fill o�the sectian belaw showing their work�s'compensation policy informatian. "'If the c�rparate officers I�ve exempted themselves,but the cwtporation has other employees,a wodcers'compensation policy is required end such an orga�izatio�n should check b�#I. I am an employer that is providireg workers'aonipensatlon�irance for mY emPloYees Below is the pvlicy i�formation. Insutance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# �.xpiration Date: Attacb a copy of the workers'oom nsa�ioa policy dectaration page(ahowing the policy number and expiratian date). Failure w secure coverage as required under Se,ction 25A of MGL c. 152 can lead to the irnposition of eriminal 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 violator. Be advised that a copy of this statemeirt may be forwarded to the Office of Investigations of the DTA for insurance coverage verifieation. I do hereb,ytcerttfy, der the p d of per}u.�y that tlie infornuu�on prov�iafed above�s true and correc� i uex�. D / -� �"J� Ph #: Offrcial use oaly. Do not write in tkis area,to be coe►rpleted by eity or town o,,(�ieiaL City or Town: Permit/License# �ssning Anthority(circle one): 1.Board of Health 2.Buitding Department 3.City/Town Clerk 4.Licensit�g Board 5.Selectmen's O#5ce 6.Other Contact Person• Phone#: www.mass.govldia � .� �� EVIDENCE OF PRQPERTY 11�1S11RANCE iali� T�US EVIDEMCE OF PROPE1t7'1f IN9URANCE JB ISSUED AS A YATCLR OF INFORMA?ION ONLY Af� OONF�S NO RiGHTS UPON - _ _�6N�►� MITERE.S7 NAMED.�t.t�lt.�� NOT AFF�IIATNEL.Y �R 1�GATNELY i►#E!!bC E�Xt�1�DCT BET�1 COYQtN1t3E AfFClRpID 9Y TNE POL�G�t-dW TH13'�tfD�OF 1#fSURANCEUOES'Nt9fi�@N�E t 1 ATIVE aR PRODt�ER.ANt}THE ADDITiONAL NrTERES7. �SUII�IG M�l�R(�,A�� ___.� _ 'L�vyds of Lc�don _ _ __ _ _ — _ - c�r,wr _ __ — .__ — — _ �� ;_jAl�e,NdE� t508)??5-3131 ___. ___� The Fair Insuranao a9'a�Y Ino. 619 Maia Strest Sv,ite 1 c�r.�rv��.iB � a�6�z_ _ __ __ _ _. __ ; --- - - _ � ��'��_=sr► _ _� __ ___�. �.�__ __ _ _ _ � ��:_ _._ __ .�_ __ _ ' . _- - - -- -- - ---- - �_�o�baoo2ass _ ____ -__�_ __- __---_ ___ -- _ _ __ __ _ -- __ - _..�__ _ ��,�e� _ _ -- ��,� � �ZSZ76365 Nancy Johnaon, DBiI: N1�iN�IC JOfII�ISffii =TI�L ___ ._.�_,—_ __ _ __ _ --- — -__ _— �.—__ _, ._ ;' PO Hox 342 �t�cnve on� � �wiwe�aa� �u►Ra 21/5J2016 11/5/24I? ;; �►�o�c►rE � �� -- -- -— --� — _ — ----- Hy�u�is MA 02601 '��OA� pROPERTY I�OI�1AT10M ' } �oc�s�_. Loc�-000z� 157 Herry l�venus . Yaraouth, MA 42673 Sae l�ttached Ov�arf la�c P�c� • , - , . T'HE POliC1ES OF M1SUR�I+ICE USl'EO �LOW W1VE �E7'1 iSSUED � THE tNiStNiE'D WIMED ABQVE FOR THE POl.iCY PERIOD INC� NBTWfTMSTM1�tNG ANY RE(iU11RE#AENT. TE'�d OR C4NUtT10N �F 11t�1( CUNTRACT OR OTHER DQCUNAENT VNTH RE�ECT TO WHK EVIDENCE OF PROPERTY INSURANCE MAY BE iSSUED OR MAY FERTAh�I,THE tNSURANG£AFFORDED BY TFfE FOLICIE&DESCR�ED HE � � • �T TO ALL TtiE TF�MS.DCC�.i1SiON5 AND OOFDITIONS OF�1 FOLIC�S. �IMtTS SFIQ1M�f MAY HAVE BEEN REDUCED BY PAtD ClA t�VERAtiE�'IIOIM �' ' . co�e�:rv�a�si�s _. _�: i �� _� ___ _ _ _— _— _.�_ -- __— _ _ ____— — �__— 300,000 ; , Buildi.nq. R�Flac�e�e�at Cost, specia i � 1,Q00,000 ocset { qenera2 lisbility , 2,OQO,OOQ: aq5 i i i f , � + , i � j � REMAt�(S C�� C�11iCEt.LI►TION �y0tit�►-�l1NX AF TME ABdVE D� � � CANC�L.LED B�RE TME E)tPiRATlON DATE TliE1�OF. NOTIGE 1 DELiVEREO tN At�ORDANCE NfFTF!THE P�0!!CY PR[1Yt310NS. 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