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Home My WebLink AboutApplication and WC �a TOWN iOF YARMOUTH BOARD OF HEALTH . APPLICATION FOR LICENSE/PERNIlT-2018 ` *Please complete form and attach atl necessary documents by December 1 S 2017. Failure to do so will result in the return of your applicahon pac et. ESTABLISHMENT NAIv1E: � � � LOCATION ADDRESS: '' �F v L.#: j - C'70�„ MAILING ADDRESS: �,� 0• irl.. � - E-MAIL ADDRESS: W` ' S .V� OWNER NAME: CORPORATION NAME�F APPL CABLE : c.,��nna ��,Q. r °�� .� MANAGER'S NAME: r TEL.#: (� � - O� MAILING ADDRESS: ' � o. V�+l D (E,Q POOL CER'TIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. ��.,_�r�...._..e�. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � -�� Cardiopulmonary Resuscitation(CPR),ha�ing one certi�ied employee on premises at a11 times. Please list the o p ) employees below and attach copies of their certificarions to this form.The Health Department will not use past ! r � 1 years'records. You must provide new copies and maintain a file at your plsce of business. f_ � fti ! � � j _ •,6 � � �1 1. 2. � r�.� a 3. 4. �� , � FOOD PROTECTION MANAGERS=CERTTFICATIONS: , _ � All food service establishments are required to have at least one fiall-time employee who is certified as a Food , Protection Manager,as defined in the 5tate Sanitary Code for Food Service Establishments, 105 CMR 590.000. ��- : `=� Please attach copies of certification to this application. The Health Department witt not use past years'records. , � You must provide new copies and m�intain a file at your establishmen� �,r.� 1. 2. PERSON IN CHARGE: L � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � � L 2. �` � �, ALLERGEN CBRTIFICATIONS: '� All food service establishments are reqi�ired to have at least one�ull-rime employee who has Allergen certification, as defined in the State Sazutary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a).Please attach copies of certificarion to this applicatian. The Health Deparlment will not nse past years'records. You must provide new copies and maintain a file at your establishmen� 1. 2. HEIMLICH CERTIFICATIONS: 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 empioyees trained in anti-choking procedures below and attach copies of employee�ertifications to tlus form. The Health Deparhnent will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL J# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT#� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT# BBcB $55 CAf3IN S55 MOTEL SI10 INN $55 CAMP $55 _SWIMMING POOL$ll0ea. _LODGE S55 �I'RAILERPARK SI05 _WHIRLPOOL SllOea. FOpD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RF.�iJIRED FEE PERMIT# (Y10(1 SEATS 5125 _CONTINENTAL S35 NON-PRO IT $30 >I00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQU[RED FEE PERMIT tl LICENSE REQIRRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT tl <50sq ft. $50 >25,000sq ft. $285 VEND[NG-FOOD $25 L<25,W0sq.ft. $1S0 � '_FR07.ENDESSERT$40 =TOBACCO SI10 �1� NAME CHANGE: $15 AMOUNT DUE _ $ �,�eO.00 *'�*•*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* $o�F-lb-1339-OZ Ba t��-c3��a�Z � j � � - I I I G� � NO'TICE NC�TI�E ' N � TC� TU M Y � d EMPLOYE ES � �� EMPLOYEES n o� .a �� s�e . The Commanwealth of l��Iassachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress St�eet, Suite 100, Bos�on, Massachusetts 02114-2017 617-727-4900 - http://wwvt�.state.ma.us/dia As required by Massachusetts General Law,Chapter 152, Secdons 21,22&3Q,this will give you notice that I (we}have}�rovided for payment to our injured employees under the above-mentioned chapter by insuring with: MA Retail Merchants WC Group Inc. NAME OF INSURANCE COMPANY PO Box 859222-9222 Braintree,MA 02185 ADDRESS OF INStJRANCE COMPANY 014000502236117 1/01/2017 - 1/01/2U18 POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardv�le St, Suite 1 Wilmington,MA 01887 Nt�ME(JF INSURANCE AGENT ADDRESS PHONE t# �'armouth Wine&Spirits LLC 484D St�tion Avenue Sou�h Yarmouth,MA 02664 _ EMPLQYER 'ADARESS EMPLOYER'S WORI�ERS' COIvIPENSATION O�FICER(IF ANY) DAT� MEDICAL TR�ATMENT . The a�ove named insurer is required in cases of p�rsonal'injuries arising out af and in the course of emplqyment t�furnish adequate and reasonable hpspital and medical services in accordance with the provi�ions of the Woxkers' Compensation Act. A copy Qf the First Report of Injury must be�iven to the injured employee. T`�ze employee may select his or her own physician. The reasonable cost of the se�•- vices providea by the treating physician will be paid by t�e insu�er,if the treatment is necess�ry and reaso�iably co�nected to the work related injury. In case�requi�ing hospital attention,emplo�ees are hereby notified that the inszuer has arranged for such attention�t the` NAM�O�HQSPITAL ADDRESS ` TO BE POSTEI� BY EMPLOYER , I ; AI}NIINISTRATION 1 � Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED_� OR WORKER'S COPvIP.AFFIDAVIT SIGNED AND ATTACHED � � ( Town of Yazmouth taaces and liens must be paid p 'or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS A1ND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For p�arposes of the limitations of Motel or Hotel use,Transient occupancy shall be timited to the temporary and short term�occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonst�ate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to conrinuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(94)days within any six(6)month period. Use of a guest unit as a residence or . dwelling unit sha11 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 OPENING:All swimming,wading and whirlpooLs which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening.PLEASE NO'FE:People are NOT aliowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudornonas,total coliform and�tandard plate count by a State certified lab,and submitted to the Health Department three(3)days p�ior to opening,and quarterly thereafter. POOL CLOSING:Every autdoor in ground swimming pool must be drained or covered within seven(7)days of closxng. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All�ood service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requxred Temporary Food Service A plication form 72 hours prior to the catered event. These fonms can be obtained at the Health Department,or�om the Torm's website at www.yarmoath.ma.us under He�lth Depariment, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. 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 seating witti waiterlwaih�ess service),must have prior approval from the Board of Hea1th. OUTDOOR COOKING: Outdoor cooking,preparation,or displaq of any food product by a retail or food service establishment is prol�ibited. NOTICE:Permits n►n annually fro�n January 1 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 FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD HEALTH PRtOR TO COMMENCEMEN'I'. RENOVATTONS N�BQiJIItE . , DATE:� �'1�. ,a.o�7 SIGNATURE:�J PRiNT NAME 8i TITLE: �C'(`,R,,�.'\,��M(��.+ C�tu 1f��2�C� x�,.ionvi�