HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2018 .
"' *Please complete foncn and attach all necessary documents by December IS 20I7.
Failure to do so will resutt in the return of your applicat�on'pac ce�—
ESTABLtSHMENTNAME: CC- • '�,�.y
LOCATTON ADDRESS: 1 — TEL.#: - � 'L�Q(�v
MAILING ADDRESS: .
E-MAIL ADDRESS: _ GT c 'C�
OWNER NAME:
CORPORATION NAME APPLICABLE : 'Y" -
MANAGER'S NAME: TEL.#:
MAILING ADDRESS: Cra�n�e'. i'-----
� �
POOL CERTIFICATIONS: � � �
The paol supervisor must be certified as a Pool Operator,as required by State law. Piease list the designated � �
Pool Operator(s)and attach a copy of the certification to this fo��'�'-'����..�.�^ z � �
i. ' 2. � �v �
` � � �7 o i'o`tt
Pool opera must list a minimwn of two employees currently c;ertified in tandard First Aid and Cammunity � v �
Cardiopulmonary Resuscitadon(CPR),having:vne certifted empioyee on premises at all times. Please list the �� - ;
employees betow and attach copies of lheir certifications to thas form.T6e Health Department will not use past
years'records. You must provide new copies and maintain a file at your ptace of business. ��
�
1. F �'� 2. 1�� rn� �"",� �
3.�T J �__,.�^ 4. �f '�'�G+J���l�G� ���
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FOOD PR4TECTION 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 540.00U. � -'
Please attach copies of certification to this application. The Health Department will not use past years'records. n +� -
Yon must pmvide new cr►pies and maintain a file at your establishment. �. I n
1. 2. '1\
��
PERSON IN CHARGE: �
Each food establishment must have at least one Persan In Chaa�ge(PIC)on site during hours of opetation. \�
� r` �
1. 2, �
ALLERGEN CERTIFICATI�NS: �
All food service establishments are recluired to have at least one full-time employee who has Allergen ceztificarion,
as defined in the State Sanitary Code far Food Servic�Establishments,105 CMR 590.009(Gx3xa}. Please attach
copies of certification to this appiicatioa�. The Health Department will not use past years'records. You must
provide new copies and maintain a file at your establishment
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee tra.ined in the Heimlich
Maneuver on the premises at a11 rimes. Ptease Iist your employees traii�ed in anti-chotc�ng procedures below and
attach copies of emp}oyee certifications to this form. The Heatth Department will aot nse past years'records.
You must provide new copies and maintain a fete at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
Loncrrrc:
OFFICE USE ONLY
LICENSB RE(ll)IRED FEE PERMIT# LICBNSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE P' tC�l
B&B $55 CABIN $SS MOTEL 5110 .�O�Z.
—INN S55 —f.;AMP S55 �SWIMMfNGP00L$li0ea. 2 00"3
_LODG£ SSS --� �_'IRAILERPARK Sf05 �_WHIRLP(30L S110ea. 1�
FOOD SERVICE:
LICENSERE UIRED FEti PERMIT# LCENSFREQUIRED FF.E E # LICENSERE UIR£D FEF, PERMITq $O{�FL"'����
=�lOi�SEATS 5200 ��OMMON V C $60 ���_I WHOI Fs°r�,'� s80 �j0�}SP-t$-6528 G�)
—RESID.KITCHEN $80 —
RETAIL SE Q ICE: Q 0oj}�Qi��S�O�
LICENSE RE UtRED FEE PERMIT# LICENSE RE UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<sosq ft�. �so >sso� R. $Z85 VL"NDtNG-FOOD S25 (�jO�l'SQ—t&�53�P(�
=<25,t)(x�sq.fi. $I50 �Rb7.EN�F,SSERT S�0 =TOBACCO $110 ���8�,3?
NAMECHANGB: $IS AMOUNTDUE _ $ �7S�O�
*�*"*PLEASE TURN OVER AND COhIPI,ETE OTHER SIAE OF FORM"*"*•
ADMIMS'TRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewat
of any license or petmit to operaze a business if a person or company does not have a Certificate of Worker's
Compensation 7nsutance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
i OR
I WORKER'S COMP.AFFIDAVIT'SIGNED AND ATTACHED
3
;
! Town of Yarmouth t�es and liens must be paid prior renewai or issuance of your permits. PLEASE CHECK
i APPRf3PRIATELY IF PAID:
YES NO
s MOTELS AND OTHER LODGING ESTABLTSHMENTS
a
! TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hatel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ardinarily 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 ofnot more than thirty(30)days,and
an aggregate of not more than ninety(9fl)days within any sax(6)month period. Use of a guest unit as a residence or
. dwelling unit shail not be consider�d transient. Occupancy that is subject ta the colleckion of Room Occupancy
Excise,as defined in M.G.L.c.b4G or 830 CMR 64G,as amended,shall generally be considered Transient.
1'OOLS
' 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 th.e Health Deparnnent to schedale the inspection three{3)
days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pooi area untii 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 Departanent three(3)days prior to opening,and quarterly
thereafter.
POOL CLUSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENIN'G:
All food service establishments must be inspected by the Health Dep�rkcnent prior to opening. Please contact the
Health Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY•
Anyone who caters witlun the Town of Yarmouth must notify the Yarmouth Health Depardment by filing the
required Temporary Food Service A tication form 72 hours prior to the catered event. These forms can be
obtained at the Health Department,or�om the Town's website at www.�armouth.ma.us under flealth Department,
Downloadable Forms.
FROZEN DESSERTS:
Frnzen desserts must be tested by a State certified lab p�ior to apening and monthly thereafter,with sample results
submitted to the Healfh Deparhnent. 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 seatiz�g witli waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,prepararion,or display of any food product by a retaii or food service establishment is prohibited.
NOTICE:Permits run annuatly from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RE'I'URN
T'HE COMPLE'TED RENEWAL APPLICATION(S}AND REQUIRED FEE{S)BI'DECEMBER 15,201�.
ALL RENQVATIONS TO ANY FC10D ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVE �4ARD OF HEALTH PRIOR
TO CONIME CEM . RENOVATIONS MAY SI P /
DATE: SIGNATURE: •
PRINT NAME&TITLE: �'" '�
xe�.iaivn
,
The Commonwealth of Massacl:usetts �;����= '
Department af Industrial Accidents
Off ce of Investigations
` 1 Congress Street, Suite 100
s Boston, MA 02I14-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
� A licant Information Please Print Le ibl
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Business/Organization Name:
i � ,
' Address:��?/���:'�
�J ' �!���
City/State/Zip: -- Phone#: �
I
� Are you an employer? eck the appropriate boz: Business Type(required):
; 1.❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantlBar/Eating Establishment
2.❑ I am a sole proprietar or parinership and have no 7. � Office andlor 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
their right of exemption per c. 152, �1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
, 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information.
**lf the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I an:an employer that is providing workers'compensation insuranee for my employees. Below is the poliey information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Secrion 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a
fine up to$1,500.00 andlor one- r 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 t v olator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for i s r ce coverage verification.
I do hereby certi , nd the a an enalties of perjury that the information provided above is true d correc�
Si ature: Date:
Phone#: � � �
Officia!use only. Do not write in this area,to be completed by city or town offacial.
City or Town: Permit/License#
Issuing Authority(circie 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
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