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Home My WebLink AboutApplication and WC d TOWN(3F YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSElPERMIT-2418 #Please complete form and attach all necessaiy documents by December IS 2�17. Failure to do so will result in the retum of your applicabon et. � ESTABLIS��vv1ENT NAME: S -- , LOCATION ADDRESS: 1 TEL.#: — .�� MAILING ADDRESS: � i E-MAIL ADDRESS: t, C� � i OWNER NAME: �� CORPORATION NAME(IF AI'PLICABLE): ` C� MANAGER'S NAIv1E: ��S4i,2, YYlc�'Yla-��t3'Y� TEL.#: �SC-3Cv,� �{�`� ; MAILING ADDRESS: .��vtn2_ ' ' POOL CERTiFICATIONS: � ' ��- The pool supervisor must be certified as a Pool Operator,as reqaired by State law. Please 1' ' e�€signated Pool Operator(s)and attach a copy of the certification to tivs form. L 2. Pool operators must list a murimum of two em 1 currently certified in standard First Aid and Community ;-� � `� ' Cardiopulmonary Resuscitation(CPR) ' one certified employee on premises at all times. Please list the �> � " ' ; employees below and attach co ' eir certifications to this form.The Heatth Depariment will not use past ;�{ � years'record�. You m vide ncw eopies and maintain a file at yonr place of busmess. �r- � ��a � �� 1. 2. 'j ',•�� 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 Frot�tion Manager,as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.0(T0. . Please attach cogies of certification to this application. The Aealth Department will not use past years'r�ords. ��- -•;=� � You us provide new copies and maintain a file�t your establishmen� � r � �, 1. 2. �-- � PERSON IN CHARGE; ' ,� Each food establishment must have at least one Persan In Chazge(PIC)o site during hours of operation. � �-- T � �. �rr� ,c.�.c�. �i��-� 2. �Psst� �/YI�.�� , ALLERGEN CERTIFTCATIONS: ' �� All food service establishments are required to have at least one full-time employee who has Allergen certification; k��,; as ilefined in the State Sanitary Code for Faod Service EsEablislunents,lQS CMR 590.009(Gx3)(a). Please attach copies of certificaiion to this applicatian. The Heatth Department will not use past years'r�ords. You must provid new copies and maintain a file at your establishmenw 1. t�1��'l�. �1�_L.Q./� 2. HEIMLICH GERTIFICATIONS: 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 esnployees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not nse past years'records. Yon m t provide new copies and maint�in a fele st your place of bnsine.ss. , i. �i�.c,�� •� 2. ��.�,ts� l�f�-� 3. 4. �! RESTAURANT SEATING: TOTAL'# � wncnvc: OFFICE USE ONLY LICENSE REQU[RED FEE PERMIT N LICENSE REQUIREI7 FEE PERMIT# LICENSE REQUIItED FEE PERMI'L# B&B $55 CABIN S55 M�TEL $110 INN $55 CAMP SSS SWIIvIMINGPOOLSIlOea I,ODGE S55 �I'RAILER PARK $105 _WHQtLPOOL SllOea FOOD SERVICE: �O�F�I`Y'V7`{� LICENSE REQUIRED FEE �j�� LICENSE REQUII2EI} FEE PBRMIT# LICENSE REQUIRED FEE PERMTf# �0-100 SEA7'S Si25��a-"—=�LFp CONTINENTAL S35 NON-PROFTf S30 >IOOSEAT'S 5200 �COMMONVIC. f60 �� —WHSro KTTCHEN S80 —O� RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREI7 FEE PERMIT# LICENSE RF.QUIRED FEE PERMTC# <SOsq ft. S50 >25,000sq R 5285 VENDING-FOQD S25 =U3,000 sq.ft. 5150 �FROZEN DESSERT S40 �I'OBACCO S]10 NAMECHANGE: S15 AMOUNTDUE _ $ (E3S.00 *+**•PLEASE TURIV OVER AI+In COMPLETE OTHER SIDE OF FORM'"'** � ADMINtSTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a persan or company does not have a Certificate of Worker's Compensation Insurance. THE AITACAED STATE WORKER'S COMPENSATION INSURANCE AF�'IDAVIT MUST BE COMPLETED AND SIGNED,OR � { CERT.OF INSUR.AN�E ATTACHED a OR � � WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED 1 Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK APPROPRIATELY IF PAID: YES,� NO MOTELS AND OTHER LODGING ESTABLISAMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordina�ily and customarily associated with motel and hotel use. i Transient occupants must have and lie able to demonstrate that they maintain a princi�l place of xesidence i' elsewhere.Transient occupancy sl�all generally refer to continuous occupancy of not more than thirty{30)days,and an aggregate of not more than ninety(9Q)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 OPE1�tING:All swimming,wading and whirlpoo�s which have been closed for the.season must be inspected by the Health Department prior to openuig. Contact the�Iealth I�partment to schedale the inspection three(3) � � days prior to opeaing.PLEASE NOTE:People are NQT allowed ta sit in the pcwl area unril the pool has been inspected and opened. i POOL WATER TESTING: The water must be tested Eor pseudomonas,total coliform and standazd plate count ; by a State certified lab, and submitted to the Health Deparnnent three(3)days prior to opening,and quarterly j thereafter. �I POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(�days of � closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Ail food service establishments must be inspec#ed by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to openuig. CATERING POLICY: � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing rhe required Tempo Food Service Application form 72 hours prior to the catered eve�rt. These forms c;an be abtained at the H�th Department,or from the Town's website at www.yarmouth.maus under Health Department, Downloadable Forms. FROZEN DESSERTS; Fmzen desserts must be tested by a State certified lab prior to opening and monthly thereaft�er,with samgle results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress seivice),must have prior approval from the Boarsi of Health. OUTDOOR COOI�NG. Outdoor coaking,preparation,or displary of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annuatly from January i to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FQOD ESTABLISHMENT', MOTEL OR POOL (i.e., PAIlVTIl�TG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRiOR TO COMMENCEMENT. RENOVA'I'IONS MAY REQ A SITE PL DATE:_�I 7 __SIGNATURE: PRINT NAME 8c TITLE: 1 � C.L. / -� xe�.ia�v» � . . _� f�-�� " _��r�- _ � The Commonwealth ofll�fassachusetts 3�� m �� _�� Deparhnent of Industrial Accidents Office of Investigations 1 Congress Street,Suite l40 �� G t� �� Boston,MA 02114-2017 www.mass.gov/dia , ...__.._ _ . � Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�i61v i � i � - , Business/Organization Name: � S Address: �� '• � � City/State/Zip: y(',,t�'Y►UWI v� �� hons#: � �3�a ��v a 7' Are you an employer?Check the appropriate box: Business Type(reqaired): � 1� I am a employer with � employees(full and/ 5. ❑Retail sor part-time).* 6.�Restaurant/Bar/Eating Establishment i 2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl.real estate,auto,etc.) ? employees working for me in any capacity. i (No workers'comp.insurance required] 8- ❑Non-profit � 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment 1 their right of exemption per c. 152,§1(4),and we have 10.�Manufacluring ; no employees. [No workers'comp.insurance required]* 11.❑Health Care � 4.❑ We are a non-profit organization,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 *'ff the cocporate officers have exempted themselves,but the corporation has other employces,a workers'compensation policy is required and such an organizadon should check box#1. II am an empdoyer that isprovidin workers' on�pe 'on insxrance for my employees. Below is thepodicy irtfornurtion. Insurance Company Name:�p Insurer's Address: ��Q�� ('�(� City/State/ZiP:_�,��(1 �1 ��O�5� Policy#or Self-ins.Lic.# � ��i �+.--0 $ �. '�j Expiration Date: a/� I�� Attach a copy of the workers'compensallon 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 and/or one-yeaz 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 c fy under the pains and pe lties of perjury that the injormation provided above is true and correc� � Si ture: Date: /�/��// Phone#: �� o� " �� G�� Official use only. Do not write in this area,to be completed by city o�town o,fficial City or Town: Permit/License# Issuing Anthority(circle one): 1.Board of Health 2.Building Department 3.Cityl1'own Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia