HomeMy WebLinkAboutApplication and WC Cc��( I�G- `l� \Z� 20 l�
a TU1�VN UF YARMOIITH BC?ARD OF HEALTH
� �� APPLI�ATION F(�lR LICENSE/PERMIT-2018
�'"'� *Please complete£orm and attach all necessary documents by Decemher IS,2017.
Failure to da so will result in the rei�u�n c�f your application packet.
ESTABLISHMENTNAME: S �r" A ID• '
z.ocal�roN aDDREss: f(� � Ma�n, s r r L.#: �ca l7� �7�U- 3 ,��
MAILING ADDRESS:
I;-Rr2�IL ADDRLSS:���c�rs_t_�n o� . r
()W;�TF.,R NAh�SE:�a7�' f[��/.),�t-^�o,�J �� e^ S�oLa
@'e';T
CORPOKATIOIvr t�Ai�fE(IF APFLIC£1Bl,E�: �cx�boc�r�.f�n�G
MAItiAGER'S NA'14E: �cx'F'h I e-�n1 LAt�s o r�5 '��v TEL�: ;Q l'? —��C7`—3�I$�
MAILING��DRESS: 1 b0 Gra r�b Q i^rv LNF S��/�r rn ou'� �.l'�I !� O 2 Co�,t/
PC}OL CERTIFICATIUNS:
The poc►1 supervisor must be certitied as a Pooi Operator,as required by State law. Please list the designated
Pool Operator(s)and attach a copy of fhe certification to ihis forni.
1. 2.
Pool oper�tc�rs must last a minimam of two enrployees e�u-rently cei�tified in standard First�id and Ce�mmunit�r
Carcliopulmonarv tiesuscitation(CPR),having cme certifi�d emple�yee an premises at all times. Please list the = �
employees belou-and attach copies of'the:ir certitic<itions to this forrn.The Health Uepaa�tinent will not use past �
years'records. You must provide ne�v coPies and maintain a file at your piace of business. � n �
�
1. 2. � m
3. 4. rn ov '�;
� � m
� � o
r(�OI?PRO"I'EC"C']ON MANAGERS-CERTIFICAT'IQNS:
Ali foc�d service establishments are required to have at least one full-time enzployee who is certified as a Food
" Protection Managez,as defined in the StaTe Sanitary t:ode f�r F�ad Serviee�stablishmenta, 1�5 GMR 590.004.
Please attach copies of certification to this applicaiic>n. The Realth I�epartment will not use past years'records.
You must provide new copies and maintain a file at your establishmeut.
r'
1. K�-�-h��� c��o� .��� �. r;,: � �:�
� ,..�
I'ERSON IN C�IARGE: �::>.
Eacl�load establishment must have at least one Person In Cliar�e{PIC}on site during hours of operation. ° r�
�. , �,�,��
A1.LBRGF�N CER'I`IFICATIONS: � ��
AIl food service establishments are required tc�have at least one fu11-time employee who has Aller�en certification, �"� ;°"�
as defined in the State Sanitary Code f�r Food Service EsEablishments,105 CMR Sy0.009(G}{3)(a). Please attach � �;,
copies of certification to this applicatic�n. The Health Department will not use past years'reeords. You must �, ,� :"
provide neav caPies and maintain a file at y�our establishnaent �
�. '�-I'�I�e�e�.t 1--�4rso N ��� 2.
HEIMLICH C�RTIFTCATIUNS: �
Att faod service estahlishments with 25 seais ar�ore must have at least one empioyee trained in the Heimlich
Maneuver on the premises at all times: Please list your employees tr�ined in anti-choking procedures below and
at#ach copies of emp(oyee certifications to this Potm. The Health Department will not use past years'records.
You must provide new copies and maintain a�le xt your��lace of business.
l. �
3. 4.
RESTAURANT SE�1TI!�TG: TOTAL# �O
OFFICE USE ONLY
LODGI'YG:
L10E,NSFREQL!1RE�D hF.E N MI'# �I(�E�NSER�QUCRE.D FEE CERMIT# 1.iCLI�SF:RFQLitREt) FEE t�EKMTT'§
�_BR.B $SS �L�_��j (.AHiti $55 A40TEL $110 _—....._._ ......
_ Il�`ti $5S ___._._ CAMP $55 _SWIMI�IING POOL$!IOea
I,ODOF �55 1'RA[LERPARK $iR5 WHIRi.PO(?! $Jlf�ea.
FO011 SERVIGL:
I,tCIiI�SFRF.,Ql.iIRFD FF..F., PPRMIT# IICFNSF,ItLQUt[tGD N'EE PGRMI'F# I,ICENSEREQI`1RED F'EE PEt2M1'i';�i
�D-1QtlST-A"1'S $125 �t.�_��, (()Td7'1M�1'tAL 53i �O:V-PROFII' S30
_lOQ SEATS �'_0O _ �_COMMON b'IC. �60 ��F) __ WHQi,fiSALr $RQ —
RETAIL SERV ICE:
--ItESID.tkITCH£'+I $80
LICENSGI2GQLIRED f''EE PERMI`I't€ IIC.P;NSF.RI�QCIR.N,ll FEE PERNIIl'# LICLNS[:REQtiIK6D FEE PERb9,IT#
=50 sq.it. 55Q 25.004 fq it �?�5 _._ _..__.._ VFNI?ING-F06D $25
<25,DOO sy.ft. $150 ----_ -----
_ —f ROLF,�I t)1 SSF.,R'I' $40 �TOBAL:CO $110
nn�v►�:cxn[vice: �rs AMOL'NTDUE = $ ���.c��
"***#PLEASE:'1'IJRN OVER AND C�MPLETL Q1'HERSIDE OF Ff}RR�iK**x� j1O/1 r `Ip`�2/�G� �-- ,
W tJt�. �(�� d<J�
�o1kF,���— la3'] _
AnMINiSTR.4TION
Under t:hapter 152,Section 2�C,Subsecti�n 6,the T'own of Yannouth is now required to hold issuance or renewai
ol any license or permit to operate a business if a�erson or coinpany does not have a Certificate of Warker's
(:�n�pensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION iN�URANCE
A[+F'IDAVIT MUST BE COMPLETED r�ND SIGNTT3,OR
CERT.UF Ii�ISUR�INCF,A"I'�:ACHI;D_--
OR /
WORKGR°S COMP.AFF�DAVI��SIGNED AND ATT�CHED ��
Towm of Yannouth tases and liens must be paid prior ta renewaE or issuance of your permits. PLEASE C`HFCK
APPROPRIATELY IF Pr�ID:
YES� Nt}__
MOTE(,S AND OTHER LODGINtU ESTABLISHMENTS
TI2�INSIENT OCCUI'ANCI': F'or purposes of the limitations of Motel or fIotel use,"I'ransient occupancy shall be
litnited to the temporary and short term occupancy;ordinaril,y and customarily associated ti ith motel and hotei use.
Transient occupants must ha��e and be able to demonstrate that they maintain a principal place ot reside�xce
elsewhere.Transient oecupancv sha31 generatly refer to catrtinuat�s occupancy o,f nat more than thirt�(30)tlays,and
, an aggregate of uot more t6an ninety(9�)days withir�any six(6)tnanYh period. Use of a�uest ut�it a�a residence or
dwelling unit shall not be considered Ctansient. Occupancy tl�at is subject to the collection of Room Oecupancy
Excise,as defined in M.Ci.L.a 64G or 830 C_'v1R 64G.as amended,shall�enarally be considered Transient.
POOLS
POOL OPENING:All sc��inlming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to openin�. Contict the F�ealth Departm�nt Yo schedule the inspection three(3)
days prior to opening.PLEASE�10`I'G: People are NO'I"al'lowed to sit in the p�oi area until the pool has be�;n
inspected and opened.
POOL WATER T�STING: "I he water must be testect f«r pseudomonas,total coliform and standard plate caunt
by a State certified lah, and submitted to the}�ealth Department three{3}days pri�r to opening,and quarCeriy
thereafter.
PC?OL CLOSINC�:I:very outdoor in��r�und swimming pool must be drained tn•c�vered�vithin seven(7}day�s of
closin�. .
FOOD SERVICE
SEASONAL FOt}D SERVICE OPENING:
All food service establishments must be inspected hy the Health I)epartment prior to opening. Please contact the
I[ealth I�e�artment ta schedule the inspection three(3 j days prior to opening.
CATFKING PULICY:
Anyone who caters�vithin the To�s�n of Yarmouth must notify the Yarmauth Health Department b�r filing the
required Tempc�rar} Food Service Applicatiou fom� 7? hours prior to the catered event. These forms can be
V obtained at t:he l lealth I)epartmeut,or from the"1'own's website at www.karmouth.ma.us under Health Depvt►nent,
Do��nloadable Forn�s.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results
subinitted ta the F�ealfh.Department. Failure ta dc�so will result in the suspznsion or revoca�ion of your Frozen
Dessert Permit until the above ternis have been met.
OUTSIDE CA�'F.,S:
C�utside cafes(i.e.,ou#door seating with�vaiter(waitress setti�ice),must have prior approval from the Baard c�f�FIealth.
OUTllOOR COOK[NG:
�utdoor cooking,preparation,or dispia}of any food praduct b�-a retail or food service establishment is prohibited.
N4TICI::Permits tun annualty from Janaary 1 to Decemher 3 3. IT 1S YOliR RESPONSIBILITY TO RET'UIZN
THE COMPI;L"I'ED RENEWAL AP:PI.ICA'I'[O'�`(S)AND REQtTIR:ED FEE(S}BY llECEIviBER 15,2017. �
AI.,I:, RENOVATIONS TO ANY Ft)OD ES`CABLISIII�IENT, MOZ'EL OR F�OL (i.e., PAINTING, NEW
EQUII?MI�NT,EZ'C.),MUST BE REPORTED TO�ND.APPR�VED BY THE BOARD OF HEAI..TH PRIOR
TO C(�MNIENCEMEN"I�. RENOVATtO�iS�tAY Rl�f�t�[RE A S["CI;:PI.AN.
DATE: ° Z ( SIGtvTATt'KE
PR1NT NAME&TITLE: ��t.'}VJ �e.��+.J �,/4/�5 O Ill �
xev.t0/t2;t7 �
�;.
� _� The Commonwealth ofMassachusetts t �� �����°��� � ��
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
' Boston, MA 02114-2017
� � ��
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�ibly
Business/Organization Name: j�N��r-d (l�SG c�.�n A�� �uS .�ne (' $nr 6
Address: ��
dZ � S
City/State/Zip: � ,� . I�/l Phone #: (p � --7 --7 � � - 3 3 l �
� Are you an employ r?Check the appropriate box: Business Type(required):
� 1.❑ I am a employer with employees(full and/ 5. ❑ Retail
�
� or part-time).* 6. ❑ RestauranbBar/Eating Establishment
` 2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl. real estate,auto,etc.)
iemployees 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 �0.❑ Manufacturing
no employees. [Nc�workers' comp. insurance required]*
4.❑ We are a non-profit arganization,staffed by volunteers, 11.❑ Health Care
with no employees. [No workers' comp. insurance req.] 12•� Other �dS 1 �a� �-�-
*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#t.
I um un employer that is providing workers'compensation insurance for my employees. Below is the po/icy 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 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
c�f up to $250.00 a day against the violator. Be ad��ised that a copy of this statement may be forwarded to the Office of
Investigations of the D[A for insurance coverage verification.
I do hereby certify, nder the pains and penalties of perjury that the information provided above is true and correct.
Si natur " ��� Date: f�`7 ��
Phone#: �/ � "' � �� —',�-..� �� �
Official use only. Do not write in this area,to be completed by ciry or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmeds Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia