HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARU OF HEALTH - k:r�
APPLICATION FOR LICENSE/PERMIT-2017
•Please complete form aad attach all necessary documems by r 16.2016.
' Failurs to do so will result in the retum of your applicatton pac�et.
+ ESTABLISfIl�IENT NAME: �
LOCATTON ADDRESS: ..Z w � GU' TEL.#: O - 7 -7 7 7/
MAILING ADDRESS: � � D !a
E-MAIL ADDRESS: ,
OWNER NAME:
CORPORATION NAME(�APPLICABLE): LC.. .
MANAGER'S NAME: l.L�f TEL.#: - laf�
MAILING ADDRESS: .�
POOL CERTIFICATIONS:
Tfie poot sqperv�or mnst t�e ceiti6cd's a Pool Opemtor,as requirai by Statc Isiw. Please ' the designate�
Pool Operator(s)and attach a eopy of the certifi�on to this form.
1. 2. a
� `� � � ,i
Pool opecators must list a minimum of employees currently certified in . First Aid a�d Community b rn � .?
Cardiopnlmonary Resuscitation(CP , vmg one certified enp loyee on ses at all times. Please list the �-- n � j:�
em plo yees below and attach copi their certifications to this for�n. ealt6 DepArtment will not aee p�st � " � „�
years'r�cords. You mast p ne�v copies and maintain n t yoar plice of baainesa. �� c� �;A a;
ri � � ;i
L • 2. � �
3. 4. `� � �,�i
�OOD PRO'fECTION MANAGERS-CERTIFiCATIONS:
�
AU food service establishments are required w have at least one fuil-time employee who is certified as a Food
Protection Manager,as defined in the State Sanitary Code for Food Service Establishmeirt.s,105 CMR 590.000. ,� �
Piease attach copies of certification to this a�lication. The Healt6 Department will not aee past yeus'records. �,��
Yoa mnst provide eew eopies aed maiatnie a 5te at your estxblie�men� ; �
�. i y le� �7v�.�.- z. ��G�i Sir'� r � �,.
�ExsoN Trr cx�r,�: K�I�i �t,ta.� Ra� on
Each food establishment must have at least one Pezson In Charge(PIG�on site during hours of operation. ' �
�L �.�I ,� r �var{� 2. � ltil�ch�.�e� �'�`��`�i��.hc� o
�— a �
ALLERGEN CERT�ICATIONS:
All food service establishments are required to have a#least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Serviee Establishments,105 CMR 590.009(Gx3�a). Please attach
copies of certification to this a�licarioa. The Heslth Deparbnent�rill aot use pAst years're�.rords. Yoa mnat
provide new copies and msinbin a tlle at your eat�blishmen�
1. �l�.i' 1lGLf� 2. �I�L�7� .�i;/'I c`il�2/)O
HEIlviLICH CERTIFICATIONS: �'�� �ec�
All food service e.stablishments with 25 s�ts ar more must have at least one employce trained in the Heimlich
Maneuver on the premises ai all times. Please list your emmployees trained in anti-cholang procedures below a�i
attach copies of employee cemfications to tUis form. The Heslth Depart�e�t will not aae past y�rs'records.
You must provide aew copies aed maietain n 8le at yoar piace of business.
i. �"� I� z. �a,rbarc� 1�crr�,c��
3. ��,R�(�c_ D 11 4. ann -7"a�c�.sp//.°
RESTAtJRANT SEATING: TaTAL#
OFFICE USE ONLY
i.oncnrc:
LICENSE REqUiRED FEE PERMiT�Y LICENSE AEQUIR£D FEE PERMiT 9 L[CENSE R£QUIREU FEE PERMiT At
8&B S55 CABIN S55 M01EL SI10
—INN s35 CAMP S55 T SWIlNHIING POOL SI IOa.
_I.ODGE S33 =IRAILSR PARK 5105 WfIDtLPOOL SI IOa.
POOD SP.ItVICE:
;�5�`�' :� ��`�5'�=������° � ��63 ���� ���
>ioo s�nnrs szoo
�rnn.s�evtcs:
LICENSE REQ[J[RED FEE PERMiT# LICENSE REQUIRED FEE PERMI'f# LICENSE REQU11tED FEE PERMIT N
<SOsq R SSO >23 000sq R 5285 VENDING-FOOD T23
`QS,OOOaq.ft. ;130 �RdZENDESSERT f40 _ �BACCO 5110
NAME CHANGB: S15 AMOUNT DUE _ $ ISaS,0�3
••s•*PLEASE TURN OVElt AND COMPLETE OTHER SIDE OF FORM•••*• (���"`�-�'� 1 I��3
,
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now rtquired to hold issuance or renewal
of any license or pernut to operate a business if a person or compaay dces not have a Certificate of Worker's
Compensation lnsurance. THE ATTACHED STATE WORKER'S COMPENSATIOIV INSURANCE ;
AFFIDAVTT MUST BE COMP�.ETED AND 5IGNED,OR
CEitT.OF INSURANCE ATTACHED '
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED . ✓
Town of Yarmouth taxes and licns must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MUTELS ANfl OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hatel use,Transiem occupaacy sb�ll be
limited to the temporary and short term occupancy,ordinarily and customarily asaociated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elxwhere.Transient occupancy shall genecally refer tq continuaus occupancy of not more than thiriy(30)days,at�
an aggregate af not more than ninety(90)days within any six{b)month period. Use ofa guest unit as aresidence or
dwelling unit shali nat be considerEd transien� Occupancy that is subject to tlie collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be consideted Transiem�
POdL3
POOL OPENIIVG:All svvimming,wading and whirlpools wirich have been closed for the season must be inspected
by the Health Department prior to opening. Contact the HealthWDepartment to schedale the inapection three(3)
days Qrior to openiag.PI,E•A.SE NOTE:Peopie are NOT ailo ai to sit in the pool ar�a wt61 tl�e pool has beon
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,totat coliform and standari plate couat
by a State certified lab,and submitted w the Health Department thrce(3)days prior to opening,and quarterly
fhereafter.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of
closing.
FOOD SERVICE
5EASONAL P'OOD SERVICE OPEMNG:
All food service establishments must be inspected by the Health Deparhnent prior to openieg. Please cantmct 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 Heatth Deparlment by filing the
required Temporary Food Service Application fozm 72 hours prior to the catered even� These forms can be
obtamed at the Health Departme�,or from the Town's website at www.varmouth.ma.us vnder Health Depertment,
Downloadable Fomns.
FRUZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to open�ng and monthiy thereafter,with sample results
submitte�to the Health Departmen� Feilure to do so will result in the suspension or revocatian of your Frozen
Dessert Pern►it wrtil the above terrns have been met
OVT5IDE CAT�S:
Outside cafes(i.e.,outdoor seating with waiter/waitre.ss service),must have prior appmvai from the Board of Heaith.
OUTDOOR COOKII�iG:
Outdoor c�oking,preparation,or display of any food product by a retail or food service e.�tablishment is prohibited.
NOTiCE:Permits nm annually from January 1 to December 31.iT IS YOUR RESPONSIBILITY TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQCTIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TQ ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAIlVTING, NEW �
EQUIPMENt.ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A STTE PLAN. �
DATE:_ /� ��/(p SIGNATtJRE:�,,� �,
PRINT NAME 8t TITLE: �h('GL L. L�1���,. e�u,+�'I @ Y'
i
Y�.v If1/i�11F . .
"� The Commonweatth of Massachwsetts
DepardKent of Ind�.strial AccideRts
U,,Q`�cc oflnves��gotio�s
1 Congress Stree�Suite 1 f10
Boston,MA 02114-20�?.
www massgov/dia
Workers' Compensation Insnrance Affidavir General Businesses
Agpticant Information Please Print Legiblv
� '/
Business✓Organization Name: ,% '/�fN h,� �Y't,f 1') � /�i �G�'1�f�
Address: `�7� �. �.� �D t'Ti�'i , l'�'II/� �..z(o'7..3
City/State/Zip: Phone#: ,,��l7 7�- 7 � 7�
Are ou an employex?Check tLe appropriate boz: Bnsiness Type(reqaired):
1.� I am a employer with_�empt�ye.es(full and/ 5. ❑Retail
or part-tirne).* 6. [�RestawantlBar/Eating Establishment
2.❑ I am a soie groprietor or partneiship and have no 7. ❑pff��d/�.��(incl.real estate,auto,etc.)
employees warking for me in aay capacity.
[No workers'comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercisad 9. ❑Entertainment
their right of exemption per c. 152,§I(4),and we have 10.�Manufacturing
no emptoyee.s.[No workers'comp.insurar►ce required)*
4.❑ We are a non-profii nrrganization,staffed by voluntaers, 11.Q Health Care
with no employees.[No workers'comg.insurance req.] 12.�Other
'.0.ny applicxet that checks baoc#t mu�also fill au the sa�ion below showing duir worlaus'ooa�sation Policy informazim•
••If d►e corpoiate oPficers have exempted themselves,b�the oorpo�lia�n 1�otha e�bYaes.e vwcloas'compeasabon WIicY is requited mod such an
o�anizmion should check box#L
I am an em,ploya tliat!s provlil�ng w+orkas'compr�rsadon ins�uranoe for n�y en�eployYee� Below ts rtlhe pollcy fiejornw�on.
Insurance Company Name: `�� ��r'� �
,
���3 Aaa�: � l-��� �or� �l� .a_., �.r�-��d , Ca�� f i ��f o��5 S
Gity/State/Zip:
Policy#or Self-ins.Lic.# �� N�� "� ��� c!' Expiration Date: � ""-2�'- �7
Attach a oopy of the workers'compenaation policy deciaration�ge(ahowing the policy nnmber and ezpir�Hon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
&ne up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in tbe form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do keneby certify,u the pa�its and pe olPer'.jur}'that the i�efonaation provfded abov+e is true and correc�
-�G'�� �Z /Z !o
I�one#: �D�'� ��' �`��a�
Of,�'tctpl use only. Do not write in thls area,to be compteted by clty os tow�e o,�icPaL
City or Town: PermitlLiceaae#
Iasaing AnthorTity(circk one):
1.Bonrd of Heaith 2.Bnildieg Dep�rtment 3.Ciiy/Town Clerk 4.Licensing Boa�rd S.Selectmen's Oifice
6.Other
Contact Person: Phone#: