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Home My WebLink AboutApplication and WC� � TOWN bF YARMOUTH BOARD OF AEALTH APPLICATION FOR LICENSE/PERNIIT-2018 *Please complete form and attach all necessary documents by D�ec H e�l S 201�. Failure to do so will result in�tbe return of your application pac cet ESTABLISHMENT NAME: � � LOCATION ADDRESS: � TEL.#: —� MAILING ADDRESS: _ �MAIL ADDRESS: OWNERNAME: /L!�.� C EG'P9 it//��C2; CORPORATION NAME(IF APPLICA.BLE): MANAGER'S NA1vIE: TEL.#: —Y1�'�"� MAILING ADDRESS:�til = POOL CERT�FICATTONS: � � The pool supervisor must be certidied as a Pool Opeiator,as required by State law. Please list'the designated Pool Operator(s)and attach a copy of the certification to this form. � z � I �� p ,�`' 1. 2. �� ¢ €`::a ��=�� Pool operators must list a minimum of two employees currenfly certified in standazd First Aid and Community =� � �'� ' Cardiopulmonary Resuscitation(CPR},having one ceztified en�loyee on�prea��s at all times. Please list the �� Health De wrtment will not use ast �� o G 4 employces below and attach copies of.ihenr certifications to this form.The p p years'e ecords. You must provide new co�and ma�ntn�a 51e at yonr place of basivaess. `� � �-: i. ' 2. _� 3. ' 4. I FOOD PROTECTION MANAGERS�CERTIFICATIOBdS: iAll food service establisl�ments are required W have at least one full-time employ�who is certified as a Food ��'� Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 GMR 590.000. Piease attach copies of certification to this application The Health Department will not use past years'records. Yon must provide new copies and maintain a 5k at yoar eetabiishmen� ; _ i i. �!/��R C�L O iv t%D 2. ��r/��¢ �t/Df/,(,�' i �"., j PERSON IN CHARGE: t x � •` � Each food establishment must have at least one Person Iu Charge(PIC}on site during hours of operation. �� '� � I � � �,,'� 1.,�� C �� D il/C71/D ; 2. r. ALLERGEN CERTIFICATTONS: � All food service establishments are requir�to have at least one fiill-time employee who has Allergen certification; as defined in the State Sanitary Code far Food Service Establishments,2 OS CMR 590.009(Gx3xa). Please attach copies of certification to ttus appiicarian. 1'he Health Department will not use paat years'reeords. You mnst provide new copies and maintain a file at yaur estabiiBhment. i. .��-�L E'Z f� ti,Q.1//� 2. HEIlvILICH CERTIFICATIONS: . AlI 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: Plea�list your a;aployees trained in anti-cholang procedures below and attach copies of employee certifications to this form. The He�lth DepArtment will aot nse past years'recorde. You must provide new copies and maintain a tqle at your place of bnsisess. �. �t,�� L�D v0 �/�J 2. 3. 4. RESTAURANT SEATING: TOTAL'# i � OFFICE USE ONLY LOAGING: LTCENSE REQU[RED FEE PERMI'f# �LICENSE REQUIRED� FSE pERM[T# LICENSE REQUIRED FEE PERMIT# B�B S55 CABIN SSS M01'EL S110 �VN S55 CAMI' 'S55 =SWIlNb1ING POOL S 110ea. , =IADGE S55 'TRAII,ER PARK 5105 ��VVHIRL..PQOL SI l0ea FOOD SERV[CE: LICENSE REQUIRED FEE # LICENSE REQUIItEDi FEE PERM[T# LICENSE REQUIRED FEE PERMIT# �0-1QOSEATS 5125 �� ._CONI'INENTAL ' S35 NON-PROfIT S30 �F��S�? i >I00 SEA1'S $200 �COMMON VIC. ' S60 � � FIOLESALE $gp j RETAII.SERVICE: ; —RESID.KITCHEN�80 _� i LICENSE itEQUIRED FEE PERMIT# LICENSE REQUITiEDI FEE PERMiT� LICENSE REQUtRED FEE PERMTT# � �C50sq�ft S30 ' >25,000sq�ft. 5285 VENDING-FOOD r25 =Q3,000 sq.R S150 �'ROZEN DESSEIL'1'S40 =�`fOBACCO 5110 , rrn�cxaxcE: au AMOUNTDUE = S (85.00 i*•*•PLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FOTtM*•'*" ADMIl�TIS�RATION Under Chagter 152,S�tion 25C,Subsection 6,the Town pf Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business itf a persdn or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STA�'E WORKER'S COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSiJRANGE ATTACHED OR' WORKER'S CO1�IP.AFFIDAVTI'�IGNED AND ATTACHED�, Town of Yazmouth taxes and liens must be paid prior to xenewal or issuence of your permits. PL�ASE GHECK APPROPRIATELY IF PAID: YES� '! NO MOTELS AND OTHER LOIxGING ESTA,BLISHMENTS TRANSIENT OCCIJPANCY: For purposes of the limiqatians of Motel or Hotel use,Transient occup�ncy shall be limit�ed to the temporary and short term occupaacy,ordinarcily aad customazily associated with matel and hotel use. Transient occupants must have and lie able ta demonstrate that they maintain a principai place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more thax►ninety(90)days within any$ix(6)month period. Use of a guest unit as aresidence or . dwelling unit shatl not be considered tiansient Occupaticy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.b4G or:830 CMR 64G,s�amended,sha11 generally be considered Transient POOLS PO�L OPENING:All svvimming,wading and whirlpooLs wluch have been closed for the.season must be inspe.cte�i by the Heatth Dep�rtment rior to opening. Contact the.�Iealth Department to sehedule the inspection three(3) � days prior to opening.P.F.�E�TO'�:People are N(Xf allowed to sit in the pool area until t�e pool has been inspected and opened. POOL WATER TESTING: The water must be tested fior pseudomonas,tatal coliform and standard plate count by a State certified lab,and submitted to the Heatth Depariment thrce(3)days prior ta opening,and quarterly thereafter. POOL CLOSYNG:Every outdoor in ground svwimming pool must be drained or covered within seven(7)days of ctosing. FOOD SERVICE SEASONAL FOOD 5ERVICE OPENING: ' All food service establishments must be inspected by the Health Depart�nent prior to op�ning. Please contact the Health Department to schedule the inspection thrce(3)days prior to opening. CATERING i'OLICY: � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary�ood Sezvice�pp lication frnm 72 hours prior to the catered evern. These forms can be obtainai at the Health Department,or3'iom the Town's website at www.yazmouth.�,us under Health Departm�nt, Downloadable Fornis. FROZEN DESSERTS: � Frozen desserts must be tested by a State certified lab prior to opening and monthly thereaf�er,with sample resutts submitted to the Health Departrnent. Failure to do so w�ll result in the suspension or revocation of your Frozen Dessert Permit until the above texms have been met. OUTSIDE CAF�`S: Outside cafes(i.e.,outdoar seating with waiter/wait=ess se#vice),must have priar approval from the Board of Health OUTDOOR COOI�TG: Outdoor cooking,preparation,or display of any foad prodµct by a retail or food service establishment is prohibited. NOTICE:Permits n�n anuually from January 1 to December�1. IT IS YOUR RESPONSIBILITY TO RET[JRN TI�COMPLET'ED RENEW.AL APPLICATION(S)AND REQUIRED FEE(S}BY DECEMgER 1S,2017. ALL RENOVATTONS TO ANY FO�OD ESTABLISFIII�NT, MOTEL C1R POOL (i.e., PAIIVTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO ANI�APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMF. T. RENOVATTONS MAY REQIUIRE A SiTE PLAN. DATE: / O SIGNATURE: --�—� PRINT NAME�c TITLE: .�C " L O �.ionan� � The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations ` 1 Congress Street, Suite 100 Boston, MA 02114-20I7 www.mass.gov/dia Worl�ers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: .�/j/ ��QQ�s�� (- ,�_ Address: �Y.S � �C� / � G� 2� City/State/Zip: Phone #: ��j— �� ,�r�/S/ Are you an employer? Check the appropriate box: Business Type(required): 1�I am a employer with�employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sa1es(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 a.nd its o�cers 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 organizaxion,staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: � Insurer's Address: � j 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andlor 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,under the pains_ d penalties of perjury that the information provided above is true and correc� Si ature: Date: ��f Phone#: — � `� Official use only. Do not write in this area,to be compteted by city or town official City or Town: Permit/License# Issuing Authority(circle one); l. Board of Health 2. Building Department 3. CitytTown Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: w�ryv.mass.gov/dia Your Renewal Workers' Compensation Policy document is ready to be reviewed online. For your convenience, a short policy summary is included below. To view the official document, log in ta The Hartford Online Business Service �enter. Please note that your bill will be sent separately as per your document delivery preferences. Your Workers` Compensation Posting Notice will be sent via U.S. Mail and will arrive in 5-10 business days. M & P SUBS INC Policy Type: Workers' Compensation Policy Number: 7611VEGZS5452 '� Effective Date: 12/09/17 ; Ex iration Date: � p , 12109/18 � ,