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Home My WebLink AboutApplication and WC �� w� � TOWN OF YARMOUTH BOARD OF HEALTH a APPLICATION FOR LICENSE/PERMIT-2017 ! *Please com lete fora►and attach all neces y �AN � 4 2��, � p sary documents b December 1 20l Failure to do so will result in the return of your applicatton pac et. -� `i��. _€: P-.��. ESTABLISHMENT NAME: � �'?• LOCATION ADDRESS: .T�r9 ,(�✓��,eC�Cts�.,.�>7 IP,f� TEL.#: sr,�'�9��j MAILING ADDRESS:��YA.t�ir,eu T�1r�A n�� E-MAIL ADDRESS: A�u6�f c� YAstoe . �,/�J � OWNERNAME: AGEFirI .+�i�'u.rt.c�i9.r�'� � � - ' � CORPORATION NAME(IF APPLICABLE):_�j/�jr>L/ fivC ' '��v MANAGER'S NAME:_ �}LCEl�'7 TEL.#: ��A .'��.�, ��7 � MAILING ADDRESS: .S�tn�f i4'�A✓3nv'� ��, 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 co e certification to this form. � 1. 2, Pool ope ts must list a minimum of two employees currently certifie ' 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. i FOOD PROTECTION MANAGERS-CER'I'IFICATIONS: .� -:� All food service establishments are required to have at least one full-time employee who is certified as a Food � y. '� '� g , tary Code for Food Service Establishments, 105 CMR 590.000. � '' Protection Mana er as defined in the State Sani �%`? y F .;,, Please attach copies of certification to this applicarion. The Health Department will not use past years'records. --I i�. �,y;�� You must provide new copies and maintain a file a�ur establishmenk �=- � " _`; 1. � 2. =-;� N " ;; �,,....�-- �z�,r, PERSON IN CHARGE: � �� Each food establishm must have at least one Person In Charge(PIC)on site duri�f operation. 1. 2. 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 certificarion to this application. TLe Health Department will not use past years'recorda. You must provide new copies and maintain a file at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishmen th 25 seats or more must have at least one employee traine ' e Heimlich Maneuver on the premises all times. Please list your employees trained in anti-choking cedures below and attach copies of emplo certifications to this form. The Health Department will n se past years'records. You must provide copies and maintain a file at your place of business. 1. 2. 3. q, � RESTAURANT SEATING: TOTAL# OFFICE USE ONLY � LODGING: LICENSE REQUIRED FEE PHRMIT# LICENSE REQU[RED FEE PERMIT H LICENSE REQUIRED FEE PERMIT# � S55 —C� $53 MOTEL s110 �,ODGE S55 _TRAILERPARK $105 _SWHIRLPOOL�LSIIOea. FOOD SERVICE; LICENSE REQQ U,,,,,,IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQP UIRED FEE PERMiT# QUO SEAI� sZ00 _COMMON VIC. $60 —WHOLESALE S80 RETAIL SERVICE: —RESID.KI1'CHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE R�QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# =<25,OOOftsq.ft. 5150 ��i �FRO�N DESSERTaS40 ��G-FOOD SZS 0� Z'fOBACCO a110 �2,,� NAME CHANGE: S15 AMOUNT DUE _ 026'0_a o — t**"•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•'*"• i$o�rr- (S-1 q t�5--02 bot�-t�P-t S-Lg ob-4�-, AANIINISTRATION 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 ATTACHED STATE WORK�R'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 pernuts. PLEASE CHECK APPROPRIATELY IF PAIp: 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 OPE1VIriG:All swimxning,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Depaztment to schedule the inspection three(3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area un61 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 Departrnent 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 Yazmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. T'hese forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.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 Departrnent. 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 COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service eskablishment is prohibited. NO'TICE:Pemuts 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., PAINTIlVG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIVIENCEMENT. RENOVATIONS MAY REQUIRE A E PLAN. ` _ DATE: /a?'S�—/7 SIGNATURE: Y�'� PRINT NAME&TITLE: A.CF�'/��ioPePA/� �o�vv�/EiP 1 R�.iaivi6 T— � The Commonwealth ofMassachusetls Department of Industrial Accidents Office of Investigations ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 � www.ma.ss.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information Please Print Legiblv Business/Organization Name:�i�i�U /,•.1� - Address: /6.- ,,r,•�-�i�,�� ;;r��' City/State/Zip: duc�'Si y�,r�,�o viry �f} Phone#:_ ��f�_,�'�/y_ qo d/' Are you an employer?Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantrBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.reaI estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insw�ance required] 8• ❑Non-profit 3:� We aze a corporadon and its o�icers have exercised 9. ❑Entertainment 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.j 12.[] Other 'Any applic�nt that chacks box#1 must also fill out the section below showing thefr workers'compensadon policy informafion. *'If the corporate offioers have exempted themselves,but the corpocation has other employees,a workers'compensation policy is requued and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees Below is the polic.y information. 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 and/or 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, der the pains and penalties ofperjury that the information provided above is true and correct. i a e: � Date: C��'--aZ�Y--�� . Phone#: �d-- ,36�i, � .30� � � Official use only. Do not write�n this area,to be completed by city or town officia[ 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.gov/dia