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HomeMy WebLinkAboutApplication and WC 6���� � TOWN OF YARMOUTH BOARD�'I�EALTH ' DEC � 2 ZO�6 � � APPLIC�TION FOR LICENS�/� T- 0 7 `^-' * �` � � - E P Please com lete form and attach all necessary�t�s by�e�e ��.� Failure to do so will result in the return of your application packet. , ESTABLISHMENT NAME: ��T r �rr�c crrno� __ _ _____ _ TAX ID: „���� „ LOCATION ADDRESS: i�q �aarn,T cTUFFT v��t��.��'�p�n��'}�,r����o�TE�n.o����3��— MAILING ADDR�,SS: c n�aF E-MAIL f�DD�,S.S: hallPt(1')�i75Cct> >ahnn �nrn �WNER NAME: r�nuT Fc �i euu � CORPORATION NAME (IF APPLICABLE): MANf1GER'5 NAME: �r/q TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: �` The pool supervisor must be certified as a Pool Operator,as required by State law. Flease list the designated P�ol Operator(s)and attach a copy of the certification to this farm. - , `� , Pool aperators must list a minimum nf two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitatian (C�'R), havi�g on�e certified ernployee on premises at all times. Please list the employees below and attach copies of their certifications ta this form. The Health Department wi11 not use past years' records. You must provicie new copies and maintain a file at your place of business. 1. 2• 3. 4. FOUll PROTF_.CTION MANAGERS - CL;RTIFICATIONS: ` All food service establishrnents are required to ha�e at least one full-tim� employee wha is certified as a ��ood Protection Manager, as defined in the State Sanitary Code for Food Serviee Establishments, 1 QS CMR 590.000. Please attach copies�f certification to this application. The He�tth Department will not use past years'recards. You must provide new capies and maintain a file at your establishment. 1 CHARLES CLARK 2 PrRSON IN CHARGE: Each food establishment must have at least one Person In Charge{PIC)on site during hours of operation. l. 2. ALI�ERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certitication, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification ta this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1 CHARLES CLARK 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one emplayee trained in the Heimlich Maneuver on the premises at all times. Piease list your emplayees 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. 2. 3. 4. RESTAURANT SEATING: T01'AL# LOl3GING: _ OFFICE USE ONLY — _ i.f � •. � � �F ��:�.tiqrj�� �.rc��.Ts��Q�!..,,,�_�•,-�_ n�„����-„- — �c�-�����--�F-R.wt�e�r- €i&R $55 CAl3 W $55 MOTEL $i l D INN $55 CAMP $55 SWIMMING PC)OI.$110ea. LOL7GE �55 �TRAILERPA1tK $l05 WIi1I2LPOOL $1t0ex. FOOD SERVICE: �L CENSE REQUIR�D FFF, I'' LICENSF Ri:QU1RED FEE PERMIT# LICENSE REQUIitr:ll FEE PERMIT# 0-100 SEATS $125 ;��� CUNTINENTAL �35 ___NON-PROFIT $30 __._>(00 SEATS $200 �COMMON V1C. $GO _�(' WfIOLESALE $80 —RESID.KITCHEN $SO RE1'�IL SERVICE: I.ICENSE R1;QUIR[iU I�F;F. PERMIT#i UCCNSIs RI;,Q(1TRF,D FEE PGRMII'# L1C'F,NSr,RF,QUIR�ED FEE PERMIT# �SQ sq.ft. $50 >25,000 sq.ft. $?83 VENDING-FOOD $2� =Q5,004 sy.h. $I50 �FR07.EN DESSL'R"l $40 �7 .-TOBACt:O $I 10 YAME CHANGE: $is AMOUNT DUE _ $ 22-r3.00 *****PLEASE TUI2N 4VER AND COMPI,F.TE 07'HER SIDE OF FORM***** go�+r---[5-�3 I 0 r O� t 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 COMP'ENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,Olt C�RT. OF 1NSURANCE ATTACHED v 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 APPROPKIATELY IF PAID: YES � NO MOTELS ANll OTHER LODGING ESTABLISHMENTS _ _ _ - _ ___ TRANSIENT OCCUPANCY: For purposcs of the limitations of Motel or f totel use,Transient occupancy sha11 be limited to the temporary and short terrn occupaney,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.Tra.nsient occupancy shall generally refer to continu�us 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. Occupaney that is subject to the collection of Room Occupancy Excise; as defined in M.G.L. c. 64C or 830 CMR 64Ci, as amended, shall gencrally be considered Transient. POOLS • NUOL;OPENING:All swimming,wading and whirlpools which have been closed for the seasan must be inspected by the Health Department prior to openin�. Contact the Health De�artment to schedule the inspection three(3) days prior to opening. PLEA5E NOTE: People are N01'allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested forpseudomonas,total colifornn and standard plate count by a State certified lab, and submitted to the Health Aepartment three (3) days prior to vpening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. _ _ _. - _ ___ _ �'OOD SERViCE SEASONAL FOOD 5E1tVICE OPENING: All food service establishments must be inspected by the Health Deparlment prior to opening. Please eontact the Health Department to schedulc the inspection three(3}days prior to opening. CATEWNG POLICY: Anyone who caters within the 1'own 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 obtamed at the Health Department,ar 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 m 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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 ta December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEF(S)BY DECEIvIBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO?EL OR POOL (i.e ATNTING, NEW �QUIPMENT,ETC.) MUST BL REPORTED TO AND APPROVED Y E�. OF HEALTH PRIOR TO COMME �E NT. RENOVATIONS MAY REQU A AN!� DATE: SIGNATURE: PRINT NAME&TITLE: ARLES CLARK ONWER Rev. 10/l2/!6 � The Commonwealth oflYlassachr�setts ""�'� ,,,, Department of Industriat Accidents � �� Office af Investigations 1 Congress Street,Suite 1 t?0 �+ B�ston, MA 02114-2017 �� � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEiblv Business/Urganization Name:___._ Charles Clark D B A Hallet's Store _ Address: 139 Main Street� __ � City/State!'Zip: Yarmouthport Ma.02675 Phone #: 508 3�2 2402 . Are you an employer?Chec[c the appropriate boY: Business'i'ype(required): 5. Retail 1.❑ I am a employer with employees(full and� � �r part-time).* 6. �Restauranuitan'Eating�,siabiishment 2. i am a sole proprietor or parmership and have no 7, �nffice andlor Sales(incl.real estate,auto,etc.) emploti•�es�vorking far me in any eapaciri�. (tio w-orkers' comp.insurance requirzdj g• � �on-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their riaht of exemption per c. 1�2, §J(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance reguired]* 11.� Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.} 12.[] Other � •Arry applicant that checks box�I musi also filI out the section below showing their workers'compensation policy information. *'"If the rnrporate o�cers have exempted themselves,but the corporacion has other employees,a workers`eompensation policy is required and such an oreanizarion�hould check box#1. I am an employer that is providing workers'tompensation insurance for my employ�ees. Below is the policy information. Insurance Gompany Name: LOVEQUIST- MURRAY INS AGGY INC __� Insurer's Address: �Ah MATN CT ____ CiryiState•'Zi WEST DENNIS MA 02670-0038 p=—. ---- _...___ ..__------._--- Policy�or Self-ins.Lic.� SBP 1065339 Erpiratian Date: 12 f 13�,2018 Aitac6 a cop,y of the wor[cers' campensation policy dedaration page(showing the�►olicy number and expiration date). Failure ta secure coverage as required under Section 25A of MGL c. 1�2 ean lead to the impositian of eriminal penalties of a fine up tn�1,St1i?.Qil and.�or c�ne-yPar impris�nment,�s well as civil penalties in the form of a STOP WORK ORDER and a fine af up to�250.O0 a day against the violator. Be advised that a copy of this statement may be forwarded to the O�ce of Investigations of the DIA for insurance co��erage verification. I do hereby certifv,under the pai n enulties erj ar the information provided abo is tr e and correct. Sienature: Date: Phone#� ��� ��� ���� �fficial use only. Do not write in this area,ta be eompleted 8y cdty>or town offiriut 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 Otfice 6.Other Cantact Persoo: Phone#: w�lv.mass.aocidia