The URL can be used to link to this page

Home My WebLink AboutApplication and WC TOWN i�F YARMOUTH BOARD OF HEALTH APPLICATION ROR LICENSE/PERMIT-2018 '�Please complete form and attach a11 necessary documents by December IS 28I7. Failure to do so wili result in!the rCtum of your applicaUon pac cet ESTA.BLISH1vvIEENT'NAME: �s l • � LOCATION ADDRESS: O 3� TEL.#: 6� 3F�/ 7-�/0 MAILING ADDRESS: � E-MAIL ADDRESS: �B�! �Q '' 'h OWNER NAME• A-as,y/_' (^....1�Yv � i�'"1 �L v CORPORATION N�ME(IF APPLICABL�E): T MANAGER'S NAIVIE: ^�1 N! TEL.#: SI.� 3 F�'7G/e MAILING ADDRESS: POOL CERTIFICATTONS: ' The pool supervisor mast be certified as a Pool Operatpr,as reqvired by State law. Please list the designated = � �7 Pool Operator(s)and attach a copy of the certification to this form. � :'�—r � � L � � 2. s ��o �'1 Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � N `o Cardiopulmonary Resuscitarion(CPR),having one certified employee on premises at ail times. Please list the -o � m employees below and attach copies of.it�eir cerhfications�o tlus form.The Health Department will not use past � � � years'records. You muat provide new copies and mauitain a file at yoar place of bnsiness. 1. 2. 3, A�. �, ,_� ._ FOOD PROTECTION MANAGERS-CERTIFICATIONS: '.��4.. All food service establishments are required to have at least one full-time employee who is certified as a Food Pratection Manager,as defined in the Sta.te Sanitary Code for Food Service Establishments, 105 CMR 590.000. , Please attach copies of certification to this application. The Health Departmeat will not nse past years'records. ;'� You must provide new copies and maintain a 81e at yur establishmen� 1. /�'�0'�/ ��J�"_- � 2• /!t�'r �`��LJ�+�zD � �� PERSON IN CHARGE; ' �` '��'� Each food establishment must have at 1 one Peison In Charge{PIC)on site�uring hours of opezation. �� ' " >` P�, l. �� ^+.-__ 1 2. !/�/�6/�l i��!�/ �`�/ ALLERGEN CERTIFICATIONS: � � All food service establishments are required to have at lea�t one full-time employee who has Allergen certification, as defined in the State Sanitary Code fdr Food Service Establishments,105 CMR 590.009(G)(3xa). Please attach copies of certification to this application. The Health Department will not use past years'records. Y�a mnst provide new copies and main`La�%K/G"'�t your establiBhment. l. �� ./� 2. . HEIMLICH CERTTIFIICATIQNS: All food service esfsblishments with 25 seats or more miust have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your e�nployees trained in anti-cholnng pracedutes below and attach copies of employee certifications to this forn►. The Health Department w�71 aot ase past years'records. You must pravide new copi�and maintaie a fite at yonr place of bnsiness. i. M��'GGC`"- 2. �'', �� 3. /! [ ' 4. !,� � RESTALTRANT SEATING: TOTAL# �� OFFICE USE ONLY i.onGn+tc: LICENSE IiEQUfRfiD FEE PERMIT# LICENSE REQUIRED! FEE PERMfP# LICENSE REQUIRED FEE PERMIT.# B&B S55 CABIN S55 MOTEL S1t0 "—TNN $55 CAMP ' S55 _SWiMMING P(�L S110ea. LODGE $54 TRAII.ER PARK SI05 VVHTW.POOL SllOea Foons�vicE: �►� 1�-b3S'1 LICENS��EQ UIRED FEE P��I�T LICENSB REQUIRED�FEE PERMIT# LICENSE REQUiRED FEE PERMIT# ,� _J__0-lAD SEn1'3 St25 ��_l�._S1�d CONTiNENTAL ' S35 NON-PROfiIT S30 >i�0 S�'ATS 5200 �COMMON VIG ' S60 .�07 _�OLESALE S80 — —.RESID.KITCHEN S80 �0 RETAII.SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREIy FEE PERMIT# LICENSE REQUIRED FEE PERMTC# <30sq ft_. SSQ ' >25 400aq ft. E285 VENDING-FOOD t25 =<25,000 sq.ft. SI50 �R�ZEN DESSERT S40 �fOBACCO SI10 NAMECHANGE: S15 AMOUNTDUE _ $ �S�J.00 *"***PI.EASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•"'• ADMIIVISTRATION j Under Chapter 152,Section 25C,Subsection 6,the Town pf Yarmouth is now required to hold issuance or renewal � of any license or pernut to operate a business if a persoin or company does not ha�e a Cerkificate of Worker's ( Compensation Insurance. THE ATTACHED STA'1�'E WORKER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLEI{ED AND SIGNED,OR � CERT.OF INSURAN�E ATTACHED � OR` � i WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED ; i Town of Yarmouth taxes and liens must be paid prior ' newal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: ' YES NO � MOTELS AND OTHER LODGING ESTABLISHibIENTS f TRANSIENT OCCUPANCY: For purposes of the limii�tions of Motel or Hotel use,Transient occupsncy shall be ; limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. ' Transient occupants must have and lie able to demonstrate that they maintain a princi�l place of residence elsewhere.Transient accupancy shall generally refer to cointinuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(94)days within any fiix(6)month period. Use of a guest unit as a residence or . dwelling unit shall not be considered ti�ansient. OccupaYicy that is subject to the coll�tion of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,sha11 SenerallY be considered Transiem. POOLS POOL OPENING;All swimming,wading and vvhirlpools which have been closed for the_season must be inspected , by the Health Departme�t prior to opening. Contact the�ieaith ent to schedule tLe ins�ch on three(3) I days prior to openung.PLEASE NOT'E:People are NOff allow to sit in tbe pool area until the pool has been inspected and op�►ed. , POOL WATER TESTING: T'he water must be tested fior pseudamonas,total coliforn►and staztdazd piate count � by a State certified lab,and submitted to the Health Department thzee(3)days prior to opening,and quarterly therea$er. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OP�I�TING: All faod service establish�ments must be inspected by the Health Department prior to opening. Please contact the Heaith Department to schedule the inspection three(3)days prior to opezring. CATERING POLICY: ' Anyone who catezs within tbe Town of Yarmouth must notify the Yarmouth Health Department by filing the requued Temporary Food Service Appiication form 72 hours prior to the catered event, These forms can be obtau►ed at the Health Departrnetrt,or from the Town's website at www.�armouth.maus under Health Departnient, Downloadable Forn�s. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter,with sample results submitted to the Healt�Department. Failure to do so w�ii resuit in ths suspension or revocation of your Frozen Dessert Pernrit imtil the above terms have been met. OUTSIDE CAF�S: � Outside cafes(i.e.,oukdoor se,ating with waiter�waitress seivice),must have prior approval from the Boerd ofHealth. OUTDOOR COOI�NG: i Outdoor cooking,preparation,ar display of any food pzodµct by a retail or food service establishment is prohibited. NOTICE:Peanits run annuallY from Januaty 1 to December 31. IT IS YOiJR RESPONSIBILI'TY TO RETURN THE COARPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE{S)BY DECEMBER 15,2017. ALL RENOVAT'IONS TO ANY FaOD ESTABLISF�NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE 1tEPORTED TO ANTy APPROVED BY Tf�BOARD OF HEALTH PR.IOR TO COMMENCEMENT. RENOVA'I'IONS MAY REQfUIRE A S PLA . DATE• `��7 _SIGNATURE: ✓ PRINT NAME&TITLE: ��' �/�`� �'iL�'�- �,ionz�i� � The Commonwealth of Massachusells �#>��!�� " Department oflndustriaZAccidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aanlicant Information Please Print Legiblv Business/Organiza.tion Name: �f�'L^°� ��e�r�� S�J��c,r�s Address: ��'� �� '� �� {�- G��'�'f� City/Sta.te/Zip: s- �'��wl�- � 0�� Phone#: .��- ��'1 � 7�f b Are yon an employer?Check the appropriate bog: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail ,�,�art-time).* 6. �j,�estaurantBar/Eating Establishment 2.LiJ' I am a sole proprietor or parinership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.in��rance required] 8• ❑Non-profit 3.❑ We aze a corporation and its officers have�ercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.�Manufacturing no employees.[No workers'comp.insurauce required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Aealth Care with no employees. [No workers' comp.insurance req.] 12•❑Othe�' 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. '*If the cocporate officers have exempted themselves,but the coiporation has other employees,a workers'compensation policy is required aad such an organizaYion should check box#L I am an employer that is prnviding wo�k�rs'e-��npepsation insurance fo`�my e �es. Below is the policy information. Insurance Company Name: �jt� l��L�"��i� �vr� � j�� Insurer's Address: a C� ��19�'S !�� City/State/Zip: /��^ C`�i9��A+'� p /'y1� b�6 sa Policy#or Self-ins.Lic.#��Oo��a�C1 � �d�` Eapirarion Date: �' 1� Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration 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 inc�,rance coverage verification. I do hereby certi nder the pains and penalties of perjury that the information provided above is true and correc� Signature: � �� Date: �d!�'°��1 Phone#: �� G Offtcial use only. Do not wrife in this area,to be co»lpleted by city or town offtciaL City or Town: Permit/License# Issuing Anthority(circle one): 1.Board of Health 2.Bnilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia