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Home My WebLink AboutApplication and WC r � ' � T4WN OF YARMOUTH BOARD O�'HEALTH � � APPLICATION FOR LICENSE/PERMIT-2018 � *Please complete form and attach all necessary documents by December l5 20I7. Failure to do so will result in the return of your application pac et. ESTABLISI3MENT NAME: t � � — �' LOCATION ADDRESS: (d'� 1 ZZ.TF 2g TEL.#: SOQ ,3a$ (O(�Q'Y MAILING ADDRESS: E-MAIL ADDRESS: w � • �,r S �O w�GU. OWNER NAME: U O CORPORATION NAME(IF APPLICABLE): 1 1 MANAGER'S NAME: a SE�P N 0 TEL.#: 'l S�9�cs MAILIIVGADDRESS: Ai ST 3 1 � O POOL CERTIFICATIONS: 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. �,..��r.,�� L 2• �� Pool operators must list a minimum of two employees currently certified in standard First Aid and Community �r`� � I Cardiopulmonary Resuscitation(CPR�,having one certified employee on premises at all times. Please list the s } � � employees below and attach copies of their certifications to this form.The Health Department will not use past ( " �� ' yeara'recor ds. You mus t provi de new copies an d main t ain a�l e a t y o u r p l a c e o f b u s i n e s s. ;,:� � , 1. E 3 `� a 2. 3. 4. F:-' � i ; ' __�____ _. __� FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department witl not use past years'records. -''�''1 You must provide new copies and�aintain a file at your establishment. `"=��' ,.,`.,� 1, 2. : � .,� PERSON IN CHARGE: � � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � 1. 2• � ' ALLERGEN CERTIFICATIONS: `'� All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicarion. The Health Department will not use past years'records. You must provide new copies and maintain a ffile at your establishment. 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 employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'records. You must provide new copies and m�intain a file at your place of business. 1. 2. 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU7RED FEE PERMIT# BBcB $55 CABIN E55 MOTEL $110 —INN S55 CAMP S55 _SWIMMING POOL$l l0ea. =LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea I� FOOD SERVTCE: ' LICENSE RE�UIRED FEE YERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEA S $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIG. $60 WHOLESALE S80 — —RESID.KITCHEN S80 �� RETAIL SERVICE: LICENSE REQUIRED FEE ��I'f#� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � ( <50 sq.ft. S50 >25,000 sq.ft. $285 VENDING-FOOD $25 � _Q5,000 sq.R $150 �ROZEN DESSERT $40 �TOBACCO $110 �' NAME CHANGE: $15 AMOUNT DUE _ $ ((00.00 **�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FOC2M***** �,e1�G�� _b-3�3�-�fy w�� o�}��—o5Z6--�`� ( I ' . : ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth 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 Compensafion Insurance. THE AT'fACHED STATE WORKER'S COMPENSATIUN INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COIvIP.AFFIDAVIT SIGNED AND ATTACHED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pwrposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal 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 than ninety(9�)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 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 NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPEIVING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the ins�ection 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 reqwred Temporary Food Service Application form 72 hours prior to the catered event. These fomns can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, 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 Hea14h Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKTNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER I5,2017. ALL RENOVATIONS TO ANY FQOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'TING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVA'TIONS MAY REQUIRE A SITE PLAN. DATE: �� I7 SIGNATURE: b'zr�-- PRINT NAME&TITLE: �°�C�H �a n-2�t �NC"� Rev.10/12/17 { � ,��. �� NOTICE NC,��T'ICE � � TO � T4 w> a EMPLO�EES � q�� EMPLOYEES -e1 , � � onwealth of Massach�.setts � T�ie Comm � ' DEPARTMENT OF INDUS'�RIAL AC�IDEN'�S ; 1 Congress St�eet, Suite 100, Boston, Massachusetts 02114-2017 � 617-727-4900 - http://www.state.ma,us/dia � As required by Massachusetts General Law, Chapter 152, Sections 21, 22& 30,this will give yau notice that I (we)have provided for p�yrnent to our injured employees under the above-mentio'ned chapter by insuring with: � MA Retail Merchants WC Group Inc. � NAME OF INSURANCE COMPANY PO$ox 859222-9222 Braintree,MA 02185 ' ADDRESS OF INSURANCE COMPANY � 014001022000117 1/O1/2017 - 1/O1/2018 � POLICY NUMBER EFFECTIVE DATES Association Benefits Insurance 299 Ballardvale St, Suite 1 Wilmington;MA 01887 NAME OF INSURANCEAGEN�' ADD�ESS PHONE# Dag�ett's Liquors 10'71 Ro�tt�e 28`�SoutheYarrr�outh,MA 02664 � EMPLOYER ADDiItESS ; ` EMPLOYER'S WORKERS' COIVIPEN�ATI�N O�FICER(IF ANY) DATE MEDICAL �'REATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and rr�edical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- � vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the worlc related injury. In cases requiring hospital attention,employees are ; hereby notified that the insurer has arran$ed for such attention at the ' NAME OF HOSPITAL � ADDRESS � TO BE POSTED BY EMPLOYER