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Home My WebLink AboutApplication and WC �� TOWN OF YARMOUTH BOARD OF HEA,LTH � � �`�'`"' $ '{�� ! APPLICATION FOR LICENSE/PERNIIT-2017 *Please complete form and attach all necessary documents by ecember 16 zol . �A� 'L 4 ZU j� Failure to do so will result in the return of yow applicanon pac e� ESTABLISHMENT NAME: l/ � �`�`"�a� LOCATIONADDRESS: /��7 Ai �5%PFf% TEL.#: S"o�'�6Q�3f�� MAILING ADDRESS:v,�YF�Pm ui.�st� �»A o��6 E-MAILADDRESS: .A�i»r��6� �/�n ��» ' OWNER NAME• .9.1��'ir� �s�e�..r.P�r9 _ CORPORATION NAME(IF APPLICABLE): U /v MANAGER'S NAME: ��iCEL�/rf TEL.#:� _3�a—�a2 37 - MAILING ADDR�SS: S'A.sr�� .,�}S i41��'YE . POOL CERTIF'ICATIONS: The pool supervisor must be certif ed 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 operato ust list a minimum of two employees currently certified ix�ndard First Aid and Comznunity Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of theu certifications to this form.The Health Department will not use past years'records. You must provide new copies and maintain a file�our place of business. / 1. 2• �,� 3. -3- � ; 4. rn Z ��t` � D FOOD PROTECTIO AGERS-CERTIFICATIONS: � � � ? �_ � All food s stablishments ate required to have at least one full-' e employee who is certified as a Food ° Pro anager as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. `� �� ease attach copies of certification to this application. The Healt6 Department will not use past years'records. �� ' � You must provide new copies and maintain a file at your establish . �'' - 1. 2. . �� ___� ;,,�. PERSON IN CHARGE: Each food establishment must have ast one Person In Chazge(PIC)on site during ho operation. 1 2�--s'./ � ALLER ERTIFICATIONS: '��~� All service establishments are required to have at least one�'time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establ�hments,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 establishme 1. 2. HEIMLICH CERTIFICATIONS: All food service establishmen th 25 seats or more must have at least one employee train the Heimlich Maneuver on the premis all times. Please list your employees trained in anti-cholan� ocedures below and attach copies of em ee certifications to this form. The Health Department will get�'use past years'records. You must pro ' new copies and maintain a file at your plate of businessy�= �• 1. 2. 3. sl:` RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT N LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMTC# BBcB S55 CA9IN S53 MOTEL 5110 INN S55 CAMP S55 _SWIMMING POOL S110ea. �,ODGE $55 _TRAILERPARK 5105 _WHIRLPOOL S110ea. FOOD SERVICE: LICENSE RE UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE RE UIRED FEE PERMIT# 0-100 SEA�S a125 _CONTINENTAI. S35 NON-PRO�IT S30 >I00 SEATS 5200 _COMMON VIC. $60 WHOLESAI.E S80 — —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT k =<25,000 sq.ft. S1�50 � �ROZEN DESSERT$S40 ZT'OBA CO_FOODfS10 �� NAME CHANGE: S15 AMOUNT DLTE _ ��' �6'' •"•*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*•'• ►3o N,F--t5-L�tO 8-6Z Botk�'P- l5-(Ro t-6 Z AAMINISTRATION Under Chapter]52,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 WOWCER'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 OPENTNG:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Heaith 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 DeparUnent 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 reqwred Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is proLibited. NO'TICE:Permits run annually&om January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN � THE COMPLETED RENEWAI,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 CO1vIIviENCEMENT. RENOVA'TIONS MAY REQ A SITE PLAN. DATE: �S/o2/S�—/� SIGNATURE: � PRINT NAME&TITLE: .�' Lv � ; n��.iaivi6 � The Commonwealth of Massachusetts Department of Industrial Accidents O�ce ojinvestigations � 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apalicant Information Please Print Legiblv Business/Organization Name: �I1�/�11 /�vN ' Address: 16– �v,�9-.�,�h�•�'�'l �1.P�J.� City/State/Zip: Gr/��/��'i'�,lD u%/f�� Phone#: ,S o��: 3��—�.3 a �� Are you an employer?Check the appropriate bos: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantlBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, �Office and/or Sales(incl.real estate,suto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• []Non-profit 3. We aze a corporation and its officers have exercised 9. ❑ Entertaintnent 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 aze 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 informaiion. •sIf the corpoiate officeis have exempted themselves>but the corporation has other employees,a workers'compensation policy is required and such aa organizetion should chedc box#1. I am an employer that is provtding workers'compensation insurance jor my employees Below is the pol�cy informatlon. Insurance Company Name: Insurer's Address: City/Sta.te/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and eapiration 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 andlor one-year imprisonment,as well as civil penalties in the form 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, nder the pains and penalties of perfury that the information pravided above is true and correct. i Date: �— � � Phone#• a Official use only. Do not write in th�s area,to be completed by ciry or town offuiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Hea1tL 2.Building Department 3.City/Town Clerk 4.Liceusing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia