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Home My WebLink AboutApplication and WC, ' ��'�i� � TOWN OF YARMOUTH BOARD OF '�H ` �' �� APPLICATION FOR LICENSE/PERM �Sr OCT � 9 2O�7 �" *Piease complete form and attach all necessary doc nts b� ec 1 �'` � Failure to do so will result in the return of your appiicafion pac et. H EF,LTH DEFT. ESTABLISHMENT NAME: � � ' • - / LOCATION ADDRESS• �r�`n��e p� .L� �`,�n�2T�vlp TEL#• 5`0�- 3�2-3,3 f� � MAILING ADDRESS: oa2G 7 E-MAIL ADDRESS: � OWNER NAME: i CORPORATION NAME(I APPLICABLE):_�i� y �!c/!f �u,C;�s�.l�`hc�S ,(�l' MANAGER'S NAME: S@-w-Q � TEL.#: ,� 2�,��.._ MAILING ADDRESS: SGa-w�.2._ POOL CERTIFICATIONS: The poot 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 Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of the'u 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. i. ►�CC�3-I�tD ��►7/�AJ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. �Q�--iP (�. (aa./V I� 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 far Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certificarion to this application. The Health Department wilt not use past years'records. You must provide new copies and maintain a file at your establishmen� 1. '1/1�1a.�1_U �• ��1 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more 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 t"ile at your place of business. 1.__��' 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE . PERMIT# LICF,NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S55 CABIN S55 MOTEL 5110 INN �55 —CAMP S55 —SWIMMING POOL S110ea _LODGE $55 =TRAILER PARK E105 _WHtRLPOOL $110ea FOODSERVICE: '�..r��" �� -.n�-� LICENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT M LICENSE REQUIRED FEE PERMtT# 0-100 SEAT'S 5125 _CONTINENTAL, S35 NON-PROFIT S30 � —>100 S�ATS S200 COMMON VlC. SfiO WHOLESALE S80 �AESID.KITCHEN S80 RETAIL SERVICE: 8a��,� LICENSL'REQUIRED FEE PERMfT# 'LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE Pk,RMIT# �� <SOsq ft. SSQ >25,000sq ft. $285 VENDING-FOOD 325 `—<?5.000sq.ft. $150 =FROZENDESSERT $40 ;fOBACC� 5110 � O� NAMECHANGE: 515 AMOUNTDUE _ $ w=O� *°"*•PL�ASE TUR?v OVER AND COMPL€TE OTNER SIDE OF FORMt�*i• ADMINISTRATION Under Chapter]52,Section 25C,Subsection 6,the Town of Yarmouth is now required to hoid 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 CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK AFPROPRIATELY 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(9U)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered gansient. 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 whulpools which have been closed far the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspecNon three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pooi area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested far 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 Hea1th 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.,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 Healfh Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Board of Health. OUTDOOR COOKING: 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 RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TH OARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS U A SITE DATE: �r !�.�SIGNATURE: �� PRINT NAME&TITLE: Re�.��,z�» or�x�en-�v�i2-c2-7�,2 r � The Commonwealth of Massachusetts Print Form Department of Industrial Accidents � Office of Investigations l Congress Street,Suite 100 Boston,MA 02114-Z�17 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apalicant Information Please Print Le,�iblv Business/Organization Name: �D�- � �,A� ,�p�,¢.�e..,��5�,��Q �� Address: � � -�,`n9'�'�.,t�1vtP� �� `�Gt�zr�ce�i l�c��l�Yd Z�� City/State/Zip: O�� 7,j Phone#: Are yo empbyer?Check the appropriate boa: Business Type(reqnired): l. I am a employer with T� employees(full and/ 5. �etail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. �pgi��or Sales(incl,real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we ha�e 10.0 Nlanufacturing no employees. [No workers'comp.insurance required]* 11.�Health Care 4.❑ We are a non-profit organir�tion,staffed by volunteers, with no employees. [No workers'comp.insurance req.) 12.�Other 'Any applicazd that checks box#1 must also fill out the section below showing their workers'compensation policy information. "`If the carporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#i. I am an employer that is provxdiaeg workers'compensation i�rsurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Earpiration Date: Attach a copy of the workers'compensation policy de�laration page(showing the policy number and ezpiration date). Failure to secune coverage as required under Section 25A af MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,50(}.00 and/or one year imprisonment,as well as civil penatties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day agaimst the violator. Be advised that a copy of this statement may be forwarded to the Office of Iirvestigations of the DIA for insvrance coverage verification I do hereby certify, �nder the p ' an '^ oJperjury that the infarmation provided above is hue and correc� i n : ja / l� �#� a�- a?- 4�6 Offacial use only. Do not write in this area,to be c�ompleted by city or town offuiat City or Town• Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Licensing Board 5.Selectmen's Off"�ce b.Other Contact Person• Phone#• www.mass.gov{dia