HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH ��(, (�� �]
. i , � APPLICATION FOR LICENSE/PERMIT-2017 + � '��`^"��V '��=`�
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' *Please complete form and attach all necessary documents by December 16.2016.
Failure to do so will result in the retum of your application packet.
ESTABLISHMENT NAME: Z T ID•
LOCATION ADDRESS: TEL.#: —
, MAILING ADDRESS: ('� Da,$�
j E-MAIL ADDRESS: -�
i OWNER NAME:
� CORPORATION NAME(IF PPLICABLE):_
MANAGER'S NAME: o.��'0.`►.3 TEL.#: " —��i��
MAILING ADDRESS:��p r� w o�-ti� ��� ..�•.���5 �a�`�
� POOL CERTIFICATIONS:
� The poot supervisor must be certitied as a Poot Operator,as required by State law. Please list the designated
I Pool Operator(s)and attach a copy of the certification to this form.
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IPool operators must list a minimum of two employees cunently certified in standard First Aid and Community
; Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the
eanployees k+�lativ and attach copies of their certifications to this form.The Health Department will not use past
i yesrs're ds. You must provide new copies and maintain a file at ur piace af busine s.
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FOOD OTECTION MANAGERS-CERTIFICATIONS: � > t�^.► F
All tood s ice establishments are reyuired to have at least one full-time employee who is certifie as a Food � �
P r o t e c t i o n M e r,a s d e f i n e d i n t h e S t a t e S a n i t a ry C o d e f o r F o o d S e r v i c e E s t a b l i s h m en ts, 1 0 5 R 5 9 0.0 0 0. �- t�
Piease attach copi of certification to this application. The Health Department will not use st years'records. -� N
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You must provide n copies and maintain a file at your establishment. ;� �
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PERSON IN CHARGE: ,,,�
Each food establishment must ha at least one Person In Charge(PI(,�•tSn site during hours of operation.
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ALLERGEN CERTIFTCATIONS: u�
All food service establishments are required t ave a east one ful]-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food ce Establishments,105 CMR 590.009(G)(3)(a). Please attach s'�� ' ,��
copies of certification to this application. T6 e th Department will not nse past years'records. You must ;
provide new copies and maintain a file your es blishment. �
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HEIMLICH CERTIFICAT S: ��
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All food service establ' ents with 25 seats or more must ha e at least one em�loyee trained in the Heimlich � ��
1Vlzr.euv�r or.the pre ses at aii times. �Iease iist your employe trained in anti-choking procedures below and -
attach copies of employee certificarions 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.
I• 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PHRMIT# LICENSE REQUIRBD FEE PF,RMI']'# I,ICENSE REQUIRED FEE PERM[T#
— CABIN $55 MOTL'L $110
--�� $$5 CAMP $55 =$WIMMINGPOOL$110ea.�b��
_LODGE $55 =TRAILER PARK $105 _______ _WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FGE PERMIT# LICENSE REQUIRF,D FEE PERMIT# L[CENSE REQUIRED FEE PERMI't#
�1 O�SEATS $200 _COMb10NVI�CL $60 _--__ —WHOLES�ALE $80 — --
RETAIL SERVICE:
—RESID.KITCHEN $80 —
LICENSE REQUIRED FEE PGRMIT# LICENSE REQUIRF,D FF,E PERMIT Ji LICENSE REQUIRED FEE PERMIT#
<50 sq.R. S50 >25,000 sq ft. $285 VENDING-�OOD $25
_ <25,OOOsq.ft. $150 _FROZENDFSSGRT $40 —TOBACCO �$110 =
NAME CHANGE: $IS AMOUNT DUE _ /rQ v
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•*°**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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% r ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE AT'�'ACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OP INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
TTansient occunants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspeeted
by the Health Department prior to opening. Contact the Hea1th Department to schedule the inspection three(3)
d$ys prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea 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 ttu•ee (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 FO�D 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.
FRO�E!!T DESSERTS: _
rrozen 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 CAF�S:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY 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 RE IRE A SITF.PLAN.
DATE: / � � �SIGNATURE:
�
PRINT NAME&TITLE: _ q/Z.
/
Rev.IO/12/16
� The �'ommonwealth of Massachusetts
� Depariment of Industrial Accidents
O�ce of Investigations
' 1 Cor�gress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Bnsinesses
A licant Iaformation Please Print Le 'bl
�----
Business/Organization Name: �- �'' � �''J ` ^
Address: � ��� ������E'l� ,��'�' �UG
City/State/Zip: r���✓�����1��' Phone #: �'-,/ ,z--r��'�1'�+�,�
Are you an employer?Check the appropriate box: Business Type(reqnired):
1.❑ I am a employer with employees(full andJ 5. ❑ Retail
_/orpart-time).* 6. ❑ RestaurantBar�atir►gEstablishment
2.[�' I am a sole proprietor or partnership and have no 7_ (� Office and/or Sales(incl.real estaxe,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g� ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainmerit
their right of�xemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* �l.❑ Health Care
4.❑ We are a non-profit organization,staffed hy volunteers, �,/
with no employees. [No workers' comp. insurance req.] 12.1.�Other
"Any applicant that checks box#I must also fi!1 out the section below showing their workers'compensation policy mformation.
**If the corporate officers have exempted themseives,but the corporatian has other employees,a workers'compensation policy is required and such an
organization should check box#i.
I am an employer that is providi workers'compensation insu ance for my employees. Below is the policy anformation.
Insurance Company Name:� �/r��11�h w� � � �,�� rt�.%-
Insurer's Address: �� '7�„//��ih ��
City/State/Zip: .� ���
Policy#or Self-ins.Lic.# �C �� ��� �� ��xp�aEion Date:_I���
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dxte).
Failure to secure coverage as required under Section ZSA of MGL c. 152 can lead to the imposition of criminal penalties of a
fne up to$1,504.�0 and/or�ne-year impris�nme:�t,�.s wpll as-civil penal�ies ir.the form�f a�T�P�JJORK ORDER�.nd a f:ze
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ot�ice of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, ender the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: ' •�-'^— Date: �
Phone#:
Of,ficial use only. Do not write in this area,to be completed by city or town offcial
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 Office
6.Other
Contact Person: Phone#:
www.mass.govldia
IMPORTANT
If tfie certficate hoider is an ADDITIONAL INSURED,the policy(ies)must be e�dorsed.A statement
on this cerGf'icatc does not confer rights to the certificate hoider in lieu of such endorsement(s).
If SUBROGATION IS WAIVED,subject to the terms and condiUons of the policy,certain policies may
require an endorsernent A statement on this certficate does not c�nfer rights to the certificate
, holder in lieu of such endorsemen#(s).
�
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s),authorized
representative or p�oducer,and the certficate holder,nor dces it aifirtnatively or negativety amend,
extend or alter the eoverage af#orded by the policies listed thereon.
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