HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATIUN FOR LICENSE/PERMIT-2017 ����
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'�Piea�e compl�te form and attach att necessary documents by� b
Failure ta do so witl result in the r�ttu'ri af your applicahon pac��
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LOCATION ADDRESS: 1l� 1 � �4 rN'mo�� or TE .#: 0 �3�(n O
MAILING ADDRESS• f� (9 n�to o D (fl
E-MAIL ADDRESS: �' UG oukb
OWNEI�NAME: �D e'1 A L`�0.rG�.I�A �;:'�
CORPORATIONNAME(IFAPPIJCABLE);_�iG,�kS D�kbaC,L �^� �'
MANAGER'S NAME: o f1 f,�r'�, TEL.#: 3�a 338a- `,� n r�� �
MAILINGADDRESS: l(ol 1200 ,19�1 �rv�o Oo . YhA D�(��� __ �:.,�
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POOI.C�TtTIFICATIONS: �7 �-;'j
TLe pool supervisor mnst be certified as s Paol Operator,as required by State lxw. Piease list the designated ��t = s
Pool Operator(s)and attach a copy af the certification to this form. .=j �
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1. 2• �
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Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
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emgloyces belaw and attach copies of their certifications to this�orm.The�ealth Depariment will not use past
years'records. You must provide new copies and maintain a file at your place of bnsiness.
i. 2. -
3. 4. ��N
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FOOD PROTECTION MANAGERS-CERTIFICATIONS. ��'�
Aii fo�d seYvice e"s�ablishQient"s are require��o have at Ieast one Yull-tiine esripioy"ee vubb is cei�i��as a�o� -
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. �
Yoa must provide aew copies�nd maintain a fele at your establishment.
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PERSON iN CHARGE:
_ . . _ _ - • -
�ac�i tood esia�it�shinent must`have at ieast ane Peeson"In C;harge(�'It;j u�site deuu���o�us at`ope�.t.icm.
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ALLERGEI+1 CERTIFIGATiONB:
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 certificarian to ttus application. The Hexlth Department wiil not use past years'records. You must
gravide aew cogies anc�e�saintsin a file at yoar establ�s���.
1. I JU Y����G�.� _2.��Y1 �Ol�l.��U �'�I
�IMLICH�ERTIFIGATTt2td�:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimiich
Maneuver on the premises at all times. Piease list your ernployees trained in anti-chokmg procedures below and
attach copies of employ�certifications to this form. The Realth Department wili not use psst yeara'records.
�'�u�ni�ruv�aie n�w��i�s and m�#�i�s�fit��ef yanr p�aec af basin�.
2. ��H I�U fY.�.pGi� 2. �t,�tL�,� (.t)�✓``�
3. t SYv�� 4. Vv1��65�1 L �
RESTAURANT SEATING: Ti?TAL# ��
OFFICE USE ONLY
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LICENSEttEC1V(RED FEE PE[tMCCT`1P LfCENSEREQUtAED FEE PERMITiI LICENSEREQI1iAED FEE PEIiMIT#
BBcB S53 CABIN �S5 MaTEL Sl]0
—!NN SSS —CAMP S55 SWIMMING POOL St IOea.
LODGE $55 _TRAILER PARK SI05 ,WHIRI,POQL $I1(ka.
FOOD SERVICE: R�{J
LICENSE AEQUIitED EEE �� ��CONTINEN�T�AL��5 PERM[T A / LEGNON-PRO�[TREi? �EE�E �6AMIT#
�0.100 SEA�'S 5125 'j�
>100 SEATS $200 �COMMON VIC. S60 �4b —'WFIOLESALE S80
— —RESID.ICITCHEN S8U
RETAII.SERVIC&:
LtCENSE REQtI1RED FEE PERMIT�l LICENSE REQiJIRED FEE PEitMIT# LICENSE REQUIRED FEE PERMIT#
<SOsq ft. S50 >25,000sq ft. 5285 VENDING-FOOD S25
=<25,O�sq.R. 5150 � �ROZENDESSERT S40 =POBACCO SI1D
IYAME CHAIYGE: sts AMQUNT DUE = S 1$�+•�.10
,��aecRI.EASE TURtV OVIIt APID CO�tPLETE OTHERSIDE QF FQRMr"+'■
� The Commonwealth of Massachusetts
Department of Industrial Accidents
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1 Congress Street,Suite 14Q
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Workers' Comgensation Insurance Affidavit: General Businesses
A�uli�ant infarmation Flease�'rint�.eeiblv
Business/C?r�anization Name: ,��al,� D��Lk �L _
Address: I(�I �.o�r f�I�"
eity/Sta�elZ�g: ��mv J-� �� �1a- D�(� S�Phune#: 5DS 3(9�-�Cn`� b
Are ypu an employer?Chezk the appropriate bog: Business Type(reqnired):
i.� 1 a�a empic�3er�,�t� I v esnployees{fuli atit� �. ���a'
or part-time).* 6. Q�Resta.urantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑p���d/or Sa}es(incl.reaI estate,auto,ete.)
„emmploy�es working for me in any eapaei�y.
� $. �Non-profit
{No worlcers'comp.insurance required]
3.❑ We aze a corporation and its officers have exercised 9. ❑Entertainment
weir rig�i o�exemption per c. i��,g 1(4 j�and we hnv� �U.�Manufacturing
no employees.[No workers'comp.insurance requiredJ* 11.Q Hea1th Care
4.❑ We aze a non-profit organization,staffed by volunteers,
wiih no emglQyaes. [No warkers' comp.insurance raq.J 12.(�Other
°AnY�plicant that rhxks l3ax�i must al�fill osst tfie seaion bek►w showing ihe�vroiic�ees'+�nPensation Po19cy infocmati�.
•«If the corporate officers have exempt�themselv�,but the corporation has other employees,a worke,rs'c�ompensation policy is roquired aad such an
oraaniaatian shouid c3�edc box#1.
I am an eniployer thot�sprnvlding workers'conrpensatlon it�ranee for my employees Betow is thepolfcy informatian.
Insurance Company Name: ��`G(��
Insurer's Acic�ress: ��P � �ov� ��
Gir;�Sratv.'�.p: GC t"MA c1� o� h�(.Gt D�? �
Policy#or Self-ins.Lic.# N a-�U D s� ��3 Expiration Date:���T ��7
Attach a copy of the workers'compensation policy declaration page(s6owing the policy nnmber and eapir�tioa dat�).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penatties of a
fine up to$1,SfJ0.40 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of�tc��25{�.'.�U�d�y�g�i�,�t the vic�l�tnr. �e�vi�tk��t�c�py�cf�is s�t�errt 3;�uy be fc�rw�t�s�=th��rz.�f
Invesdgations of the DIA for insurance coverage verification.
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I do hereby certcfy,under the pains and penal�i'es of perjury that the�fnnformatlon provided above its true and eorrect
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rus�ue r�' �� 3�� �� { �
pfficiat use only. Do not write ln tkis area,to be con�pleted by c�ty or town oJ�
City or Town: Permit/License# �
Issning Authority{circle one):
i.�si�`si���€�t�h Z.�u�fu���ser�rirafi 3.�i�yria�Cts�ii :.�.ic+er�i$g�r� s�.�s're�m�'���i� -
6.Other
Contact Person: Phone#:
wsvw.rnass.govldia
ADMIIVISTRATION
Under Chapter 152,Section 25C,Subseetion 6,the Town of Yatmouth is now res}uired to hold iss�tance or rcnewa!
of any license or permit to operate a business if a person or company does not have a Certif'icate of Worker's
�'o...�.r.s�t:�� L�s�.�-^j.rce. �'HE r��"k'A.�'�iED ��'A�'� �'V(3R�KEi�'S ���l�PE:tT�A7Ci�:'1 �N��,x'A.A."4TT�y
AFF�DAVIT MUST BE COMPI.ETED AND SIGNED,OR
CERT.OF INSURANCE A'TTACHED �/
_ Oi2
WORKER'S CQMP.AFFIDAVIT SIGNED AND ATTACHED
Tc,wn of Y�rt�*�uth��xes and liea�sn�ast l�g�id prior to reneu�al�r issua��c.�t�f yevr n�mits, PLEASE.CHF.C'K
APPROPRIATELY IF PAID:
YES� NO
1VIOTELS AND OTHER LODGING F,rsTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shail be
limited to Lhe temnorarv nnd sh�rk term occ�t?�ncv;orc9inarilv and ci�stam�rily assocrated vsrith mnte.l and hc�tel use.
Transient occupants mUst have and be able to demonstrate that they maintain a prinoipal piace 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 consider�i transient Ocxupancy that is subject to Tlie coll�tion of Room Occupanay
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shalf generally be considered Transient.
POOLS
P�t�tl.il�ENrP1t�:All swittinvng,wa�ing azid whii�tpools wiuch have ti�closed'tor"the seasozi mu"st be irispected
by the Health Departmentpn or to opemng. Cantact the Health 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 tha pool has been
inspected and opened.
POOL WATER TESTING: 'Fh�water ic�usE be te�ted it�r pserrc�mon�,tbtat cotiform ai►d sta�t�d pl�count
by a State certified lab, and submitted to the EEealtii Department three(3)days prior to opening,aud quarterlY
thereafter.
1'[)UL CLfi�1IVf�:���ty outd�ot tt��wid swttiimict�pt�ai musi 17e c�riiiii�or wvet�ett�itlun seven{7)_tlays of
ciosing.
FO011 SERVICE
S£A�S'Cli�1AL�t30D SER�iC�flFENING:
A21 food service estahlishments must be inspect�d by the Heaitti Depsrtrnent�rior ta opeaing. Flease contact the
Health Department to schedule the inspection three(3)days prior to opening.
�AI`�Ii�l(s'Pt)3..IG'�':
Anyone who caters within the Town of Yarmonth must notify the Yarmouth Health Department by fiting the
required Temporary Food Service Apptication form 72 hours prior to the catered event These forms can be
obtamed at the Health Departmeirt,or trom the Town's website at www.Xarmouth.ma.us under Health Department,
Dawnloadabie Forms.
FROZEI�T DESSERTS:
Frozen desserts must be tested by a State certified lab pcior to opening and monthly thereafter,with sample resutts
submitted to the Hea1th Departinent. Pailure to do so will result in the suspeasion or revocation of your Frazen
ITessert.Pez�nif uniii!he above ter�is have�een met
O[JTSIDE CAF�5:
Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health
Ot7TDUDit CODKING:
Outdoor cooking,preparation,or display of any food proc�uct by a retail or food service estab[ishment is prohibited.
Nf�tC�:�'ermits n�atuivat�y irrim Jani�ary 1"fb I7eeember 3I. IT IS YOU'R RESPd1V`SI�iiL3TY T'O RETT3RN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECENIDER f6,2016.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR PO�L (i.e., PAINTING, NEW
EC2Ll�f�M�N"T',�'fC.��II35T BE R�PQRTEII�'Cl A�tD Ai'i'RC}VEII BY THE BOARD OF HEAL'f fi P�E}R �
TO CO�iME�iCEMENT. RENOV�TIaNS A�fAAY REQUIRE A STFE PLAN.
DATE� (.P SIGNA'T[JRE:��—^�j;��lJ
PRI]VT NAME&TITLE:�DVlGt��Gl r� ' 0 t.t)t'�`G{2
Rcv_t0/IL16
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�s requirec�Tb�Massachusetts �ener�I�aw���ixpter ��,�ections ZIk ZZ�c 3Q,this will give�au notiee
that I(we) have�rovided fnr�►�yment tc� �u.r a�j��red empl�yeec nn�ier the ���ve�nentis�ncd chapter by
' i�sur�ng�ifli:
��ta�`rr�#���ins�r��e t;c�mpa�
NAME QF INSUItANCE COMPAIYY
�1�Q�::T'U;'S'A'��-'�3�:i3��'��i1�'�'3,,, �El�a�`�',�'Ir'�,�„��'3�
�+I33J�RE�aS OF lt':SiiRAiL'CE Ci3i41PAi�ii1'
�#f������L�.3• �.€f�f�tf�fr.��:���1���.�
ppLi�y��r(g�K EFFEC'I'IV�DATES
��g�rs�������r�cc.�gc�►� 434 I�r��� �t�,����th ��€��.�, ��#��
Iv�.tviE t'3�'ifiiSi.�'f2fiNCE AciEN.i. AUDitESS
Slack's �utback InC
D$�J�cl�f�#�ac�C� 1fi1 IVlain St�Rfi�e 6A�i�d���T�armou�h�art,�fl�fi'f�
E�VIPLQYER �l.DDRESS
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r,�LiFi�YER'S v,%t}RKERS 4a�fPEl�iS�i'i'it7�+i t?rF3%ETZ(iF Al�tY j . U�`i�
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The above named insurer is required in cases of personal injuries arising out of and in th+�course of
emplo��te�t tt�furnish�daqtc�t��ttd reaso�sb�e hctspit�l�t�c�medical services i�r accarc�a�ce with thc
,prr�visir��a vf �h���rrdcer'�Cr�m��xst���a�.,A�ct����f��irst htc�c�rt n�r�r,�u�•r�ust t�c giucr�tn thc
injured employee. T�e emgloyee may select his or hesr c��n p�ty�ici�cs�.T��r��c���hl�ccrat Uf thv s�sr=
vitces�rovided by the treatia��hvsician will l��n�i��►�thg in��rQr. �f�h�tr+r�t�n�nt is�er�ccarv a,n�
�+�a��+���e��te t�e�ver�c�ealaa�d i�a��ry.���a���s��g�c�s�pi#a�a�t�e�#�s e��y�es a� -
h�reby notified that the insurer has arra�ged for such�#ten�n at the
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1ltame of Hosni#�I A�cire.e.c
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