The URL can be used to link to this page

Home My WebLink AboutApplication and WC �, � TOWN OF YARMOUTH BOARD OF HEALTH t t J:� � �� , � � APPLICATION FOR LICENS - �!AN �b;�017 ; ,�,e `, _ * Please complete form and attach all neces� ; t Ao n � � 7�er 016. Failure to do so will result in the ret�r�of ,u�'a�p�ic� ' ��i ��' � ESTABLISHMENT NAME: C 2� -.�r- E�L TA ID: ' .� LOCATION ADDRESS: ��9 ,�(r�dTF a � — 1/1/��S� Y��yrl� TEL.#: ��y-��O•- 6fs/ ' MAILING ADDRESS:__ �,¢�Ir � � E-MAIL ADDRESS: �✓1��o c .� ,� rTr��v .. �o,.rT ; OWNER NAME:_�� CE L D �/!� l/ CORPORATION NAME (IF APPLICABLE): .�'I� � (/ MANAGER'S NAME: /riJ�,�C E� C7 �I/Q�,�c� TEL.#: �Q .-� �y-f��l MAILING ADDRESS: � �'�lG � 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. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community 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. 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. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. tif�G�i C��fJ n/o' t/t� 2. ,�� l F��c`>�'vl 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. /�� C FL � .11/CJ l/(� � 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or mare must have at least one employee trained in the Heimlich Maneuver on the premises at 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. ./I�I�/�'��L J /1/� �/r�" 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 I� $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: I,ICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 �,�'j 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 _ $ ��S�ev *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ��5��Q� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 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 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 or 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.varmouth.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 food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY 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 REQUIRE A SITE PLAN. � DATE: Q/. ��/� SIGNATURE: � PRINT NAME & TITLE: �.�d�t C C—� � /1/G�G�(� Rev. 10/12/16 � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` 1 Congress Street, Suite I00 ' Boston, MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: /'��L� � � Address: �y� �� d � t-� � � Ci /State/Zi r `�P�on�#: � � ��/'— ��O �- �r �✓' � tY P� l�/�� 7`_ �/� �� `�� Are you an employer? Check the appropriate box: Business Type(required): 1.�I am a employer with�_employees(full and/ 5. ❑ Retail or part-time).* 6. [?�'�estaurantJBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl. real estate, 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. ❑ Entertainment i their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted thexnselves,but the corporation has other employees,a workers'compensation policy is requirsd and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: �� ff�'�'[ ��'�) Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # �-� !/��r Z.g �-ri��J J� Expiration Date: r��/� Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the fortn 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under�he pains and penalties o perjury that the information provided above is true and correct. Si�nature: %'` ` C__ Date• L /��jC t- Phone#: ��'� .— .2 ��` /v- � � ` Official use only. Do not write in this area,to be completed by city or toivn offcial City or Town: Permit/License# Issuing Authorit3T(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Boar3 5. Selectmen's Office 6. Other Contact Person: Phone#: �w:.rnass.gov/dia x TxE HARTFORD Policy Number 76 WEG zS5452 Policy Effective Date 12/09/16 M & P SUBS INC 459 ROUTE 28 WEST YARMOUTH, MA 02673 d+ � � o Dear Hartford Insured, o Re: An Important Message to Workers Cvmpensation Policyholders � a � The control of workplace accidents and injuries should be among the highest priorities of your � firm. Each accident wastes precious human and financial resources, and introduces � inefficiencies into your operations. From a practical standpoint, the control of accidents, and N their inevitable costs, simply makes good business sense. 0 0 N An effective loss prevention/loss contral program can save you money and aggravation, � can positivety impact your loss experience (and thus your premium), and most importantly, can = help you maintain solid control of your operations. = As a service to you, our valued customer, the Loss Cantrol Department of The Hartford in = cooperation with your independent agent, can assist you in establishing loss control strategies. = If yau wauld like assistance, please complete and retum to us the reply portion af this = brochure, or contact your independent agent. - Services Available — The following is a description of some af the services that we provide. The types of = services that may be appropriate for your business depend upon the nature and size of = your operations and the specific loss control services you have requested. The cost of = loss con#rol services may or may not be a part of your insurance premium. This - depends on the extent of the requested services, agreements stated in your insurance = policy and program, and statutory regulations that may .require us to provide loss = control services. = 1) Reference Materials — Information about loss control topics that can be provided or made - available to you to help you to enhance your lass control program. = 2) Telephone Consultation — We can hold a teleconference with you to help you to evaluate = your los5 control program, identify areas for improvement, and recommend ways to - implement such improvements. = 3) Onsite Consultation — This consists of visiting your premises and helping you to assess and remedy your loss control needs onsite. This level of service is usually only appropriate for larger, higher hazard operations. The following are examples of some of the services that could be provided onsite: Fortn 9748514th Rev.Printed in U.S.A. Page 1 of 6 Process Date: 10113/16 Policy Expiration Date: 12/0 9/17