The URL can be used to link to this page

Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTH RECEIVED �� APPLICATION FOR LICENSE/PERMIT-2017 �" *Please complete form and attach all necessary documents by Decernber l6 20I . D EC �H 7��7 Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: S `�' �i E TAX ID• TH DEPT. LOCATION ADDRESS: �I6D iZl" lo f�' O2� 7� TEL.#: O$ 36 MAILING ADDRESS: SPrI�( E-MAILADDRESS: fZMa 1 Cr2S ��Kl�ISi. �i OWNERNAME: �l_t= �Rr"10 CORPORATION NAME( APPLICABLE): G�•2 p2 /NG, MANAGER'S NAME: t�LL� O�T'�o TEL.#:J O$' �6 O ,� MAILING ADDRESS: l�r'd�GO'T (�'�WSi� /� a ` �:'.-� � � POOL CERT�ICATIONS: �� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � Pool Operator(s) d attach a copy of the certification to this form. � �.�:� I a � 1. � 2. f. � � � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community J � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the �F""�`� employees below and attach copies of their certifications to this form.The Health Department will not use past � .�:� j years records. You must provide new copies and maintain a tile at your place of business. ; � 1. ��i4 2. 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 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 will not use past years'records. You must provide new copies and maintain a file at your establishment. i. .L�}►L� �,�r'�a� 2. �iUPrN�1��sanl Sj i✓r4- PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. l'►)i�t �i��L/zL�2R� 2. �l'�C�IE I-�c�/�/'�� 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 application. The Health Department will not use past years'records. You must provide ew copies and maintain a file at your establishment. 1. .`/�� l..l�Jv10/v 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 maintain a file at your place of business. 1. ��2,C�R I�1CYlr�►2?�S 2. ��NN� F'C �L'�C9C 3. Eiil LEw� e 4. �BcCc�4 F3�2,e Y RESTAURANT SEATING: TOTAL# 2-3 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOT'EL $110 INN $55 CAMP $55 SWIMIvIINGPOOL$IlOea. LODGE $55 TRAILERPARK $105 WHIItLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �,.�>100 SEATS $200 �— �COMMON VIC. $60 �b2 _��D.C HEN $80 RETAII.SERVICE: �S� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NaME c�NCE: $ts AMOUNT DUE _ $ 2(o D�O� ****"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'*x �OI�F-1�3(�� ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pertnit to operate a business if a person or company does not have a Certificate of Warker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURAINCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED �/ OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily 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(90)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 Deparhnent prior to opening. Contact the Health Department to schedule the inspecNon 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 standard plate count by a State certified lab, and submitted to the Health Deparhnent 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 OPENING: All food service establishments must be inspected by the Health Deparhnent 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.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 Health Deparhnent. 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 with waiter/waitress service),must ha�e prior approval from the Board of Health. OUTDOOR COOHING: 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 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPR Y T OARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU SITE L DATE: I2-.�-J7 SIGNATURE: PRINT NAME&TITLE: �•tJ�LC �2vK�N OWrV�2 Rev.10/l2/16 � .. No�rc� ,�:,, NOTzcE � � TO M ~ T� � � tl EMPLOYEES �q � E�i/IPL�YEES �w� ��Oq SV�v` � The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http:i/www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152; Sections 21,22&30,this will give you notice that I (we)have provided 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 i � ADDRESS OF INSURANCE COMPANY " 014004�02163�.17 ` ' 1/O1/2017 - 1/O1/2Q18 POLIC�'NUM�ER � ' � EPFECTIVE DATES Rogers;&Gray Insurance Agency 434 Ro�te 13� Sout�i Denz2is,1VIA 02660 � NAME�JF INS�JRAN�E AGENT �AD�RESS ` PHONE!# j Oliver�rmon,:�nc. 6 $ray Farm R�ad Y�-�no�thpoi�, MA 02�75 � EMPLC�YER �; ' AD�RESS` , � EMPLQYER'S WORi�.ERS' COMPENSATION O��ICE�(I��NY), DAT�, I i . � l�/IEDICAL "TRL�AT�/IEIVT The above natned in�urer is req�ired iFi cas�s of personal�injuri�s ari�ing out of and in the cotirse of emplQyment t�o furni�h adequat� and reasori�ble h�spital �nd medical services in accordance vvith the provi�ions of the Wo�lcers' Con3pensation Act. A copy af the Pirst Report of Injury iriust be �iven to the injur�d emplayee. The employee may sele�t his 4r her a�vn physici�n. The reasonable cost c�f the se�- vices provide�by th�treating physician will be p�id by the ins�zrer, if the treatment is necess�ry and '' reasoaiably co�nectec�to the worlc related injury. rn case�requz.ring Y�ospital attention;;emplo�ees are hereb�notified that t�e insurer has arranged for such attai�tion�t the' } NAME OF H�SPITAL � � ADDRES� TO BE FOSTEI� BY` EM:PLOYER °