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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by December 16.2016. .,�.,, Failure to do so will result in the return of your application packet. m�; ESTABLISHMENT NA1v1E: /- LOCATION ADDRESS: •v� �' f TEL.#: - 0?8" MAILING ADDRESS: � / S � E-MAILADDRESS: � � Gt� ve , o�' a___._,_---_. __,m__ OWNER NAME: Ccr,�e. d'�,5 S�' �)N � i V �Lf2 5 �t-r Gci ; : CORPORATION NA E(IF APPLICABLE): Sa-►�t�e a-S' a�oa u�t �� MANAGER'S NAME: 0''ItGInQP� � � TEL.#: .j'O�f- �r�- ,�,,y =`' MAILING ADDRESS: o1y1 7 l�l�1/nr� .Sf g�'w�oU� 11�� d!o�7.5 r; - _� POOL CERTIFICATIONS: � The pool supervisor must be certitied 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. , —.r� 1.�� /-1' 2. ; � _��.� ______�_�_._a Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certificarions 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. -�k�' �;�� 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 FoodServ�ce Establishments, 105 CMR 590.000. �� Please attach copies of certification to this application. The Health Department will aot use past years'records. You must provide new copies and maintain a file at your establish�nent. \� „ �� 1. \ �QX Z V� 2�~ , PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �. � �'►�t�,l �Zc�.�.�n z. ALLERGEN CERTIFICATIONS: All food service establishments aze 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. �. A,,,�v Z�n 2. � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one empioyee trained in the Heimlich Maneuver on the premises at ali 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 yaur place of business. �. � e� �ld��e� 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B a55 CABIN $55 MOTEL $l10 —INN S55 �CAMP S55 � _SWIMMING POOL$110ea _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICEI�ISE REQUIRED FEE Pf RMIT#,�� 0.100SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 �Y%7_� >100 SEATS $200 _COMMON VIC. S60 WHOLESAi.E $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 —<25,OOOsq.ft. $150 =FROZENDESSERT $40 =TOBACCO $110 NAME CHANGE: $25 AMOUNT DUE _ $ �5.0� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*'* �N L��S�`O �T'OZ �30t�'�f S--(b(2-Cf'Z� � . { i ADMINISTRATION 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 WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR i 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 pennits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLI5HMENTS TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shoft 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: T'he water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the HeaIth 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 f 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 Yazmouth 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 Deparkment, 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 wil]result in the suspension or revocarion 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 COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUfRED 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 RE RE A SITE PLAN. DATE: � �� SIGNATURE: I PRINT NAME&TITLE: � pL � Rev.10/12/l6 i � °� `� TOWN OF YARMOUTH Boardof Health = 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-24451 " �'' Telephone(508)398-2231,ext. 1241 Div sion :�.�...._.._.._. Fa�c(508)760-3472 APPLICATION FOR A LICENSE TO CONDUCT A ; FF� f� i CU i/ RECREATIONAL CAMP FOR CHILDREN (Use back of application if additional space is necessary) - -_ _ Name of Camp: � ,._,� 1 ��E�-�10 c2 Ul - _ _ Site Address:� a � �� S � v a �� p8�� a(o�� Site Address: Tax ID Number(FEIN or SSN): E-mail Qy►q�J,Z,ct�1�1�SCp+.�rivrj-Orcr J �� Type of Camp: Day(less than 24 hrs.) ✓ Residential(24 hrs.) Hours of Operation:__ /�` / �� ' ,�pyK Dates of Operation: Opening: Jv��Q/�f Closing: 'US t �1 Q/ Name of Camp Owner: �'�,L1e, Co �',rS �z� 5 �� >�C f� ,�iaV � v�5 P.(��c� OfficeAddress:�z) �(��t� ��('��U� �G��" �.� ��fo '7� Office Telephone Number: e�'��- ��(,��C.-� 3 �� Name of Camp Operator(if different): Address: Telephone Number: Camp Director:��1,,�� Q,�� Address: �� y7 1n 1 t �)��•.� ��" 1/�a f�r��U`f'� �i�s(��,� d��v�S� Age: '�� Telephone Number: �j ' � .�j�� - �� ; Coursework in Camping Administration:�'� ��Q�' �,,, , ('��.� ��?� S�lj—Q�C�'1 Previous Camp Administration experience:_ _'S� �/ �`.��r(��` t�.�� Health Care Consultant: �.-�� M i��,' �, y�, Type of Medical License:�� j MA License number: a�a ,5� 3 �%eas�u�f Cce e M ccc! DF ,c,�s Address: �5 � r'�Jea sa vi t � w ��P, � Ad .�1 � �_Telephone:�Q� -- `,(j��,�r °'�°"5 1 of 3 i Hospital for Emergency Services: �,��e, � �-p 1�� Health Supervisor: -) Age:� Type of Medical License,Registration or Training: C� �y� �� ' �¢,v� �e��' ��rcLr Gti vlrvt Swimming Area: Yes ✓ No � If Yes: Fresh Water � Ocean Pool CPO Specific Onsite Locations: �o�;`�� S� �� ,,,�c��q �,('pp„ �y� �,�� ,� ��J Water Quality Testing Performed By: '��,��( ('��p�1.� Aquatics Director: Name: � 1\Yl e�` ,v Age: a Lifeguard Certificate issued by:��,� p� ,��a-� � Exp. Date:�l,� !"�,�0✓IRI S4�2� � J�1Ll� � �s CPR Certificate: � o��y�s Exp. Date:lv � �� N�,ho��► s��+ C ��! A�er�sa�-��Certificate: � 3 3 � �� Exp. Date: � /�f Previous aquatics supervisory experience:/t9uc��i ni✓Pc�or ¢S��v,s�r - y U��,�s WatercraftBoatingActivities: Yes '� No Describe: �uvc�k C�� °ti,,f�/�l��S s�� c�d le�— Compliant with Christian's Law: Yes '� No Food Service: Is food handles, served or prepared? Yes No � To what extent? Snacks Cooked and Served by Staff If cooked onsite, Food Manager(submit copy of ServSafe)�� Zv�ny�- �'u�ve 5�� Catered if so, by whom? Is refrigera.tion available for perishable foods? Yes ''`� No �1�� r�� e�� o�� >;�� Fire Arms Instructo • Name: i� �,,� �D v�r'ti� National Rifle Assn. Instructor's Card(or equivalent) Date certified:��(�/(2_ Expiration Date: �� ,3�� °°"°"5 2 of 3 Background Checks: Has the Camp Owner or Director obtained and reviewed the CORI and SO�I of each staff person and volunteer who may have contact with a camper? Yes i� No IMPORTANT! CONTACT THE YARMOUTH HEALTH DEPARTMENT ONE (1) WEEK PRIOR TO OPEI�TING TO SCHEDULE AN INSPECTION! THIS IS MANDATORY! OVERNIGHT CAMPS MUST ALSO SCHEDULE AN INSPECTION WITH THE BUILDING AND FIRE DEPARTMENTS. By signing this application, I acknowledge that I have subntitted all required documentation and I am in compliance with the State's minimum standards for Recreational Camps for Children,State Sanitary Code Chapter IV, 105 CMR 430.000. SIGNED: PRINTED: DATED: " � �/ See the nezt page attached for a list of documents that must be completed and submitted before your application can be fully processed. You are strongly encouraged to complete these documents as soon as possible and submit them in advance. This will expedite the process. oaiaons 3 of 3 NOTICE rt � NOTICE �. TU � � TO � � � � EMPLOXEES �� EMPLOY � EES �� The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you notice that I(we) have provided payment to our injured employees under the above mentioned chapter by insuring with: A.I.M. Mutual Insurance Company NAME OF INSURANCE COMPANY P.O. Box 4070 Burlington, MA 01803-0970 ADDRESS OF INSURANCE COMPANY VWC-100-6014316-2016A 03/31/2016-03/31/2017 POLICY NUMBER EFFECTIVE DATES 973 lyannough Road Miller McCartin dba Dowling& O'Neil Hyannis, MA 02601 (508)775-1620 NAME OF INSURANCE AGENT ADDRESS PHONE Cape Cod & Islands Council Inc Boy Scouts of 227 Pine Street Yarmouthport, MA 02675 EMPLOYER ADDRES5 05/04/2016 DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NEAREST AND BEST MEDICAL FACILITY HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER