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Home My WebLink AboutApplication and WC � � TOWN QF YARMUUTH BOARD OF HEALTH APPLIGATION FOR LICENSEfP�RMIT-2018 `" *Please complete form and attach a11 necessaay documents by Decemher I S;2Q17. Failure to do so will result in the retum of your application packet. ESTABLISF�MENT NAME: � LOGATION ADDRESS: , � � TEL.#: — MAILING ADDRESS: E-MAIL ADDRESS: ° OWNER NAME: � p �" ni �. r CORPORATION NAME(IF PPLIGABLE): � C C � �' -�—� � MANAGER'S NAME: � TEL.#: � ��v �� - MAILING ADI?RESS: �'�da�t'£r O """ � IV �;'„ POOL CERTIFICATIC?NS: � �� -O _. 6.: The poal supervisor must be certified a�a Pool Operator,as requir+ed by State l�w Flease list the designated � � �� Pool Operator{s)and attach a copy of the certifica#ian#o this form. 1 2. Poal operators must list a minimum of two employees cunently certi�ed in standard First Aid and Community • • Gardiogulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health Department witl not use past years'records. You must provide new copies and maintain a fite at your place of bnsiiccecs. 2. 2. r 3. 4. � O � FOOD PROTECTION MANAGERS=CERTIFICATIONS: �'�'^� All food service establishments are required to have at least one full-time emptoyee who is certified as a Food �-. Protection Managcr,as defined in the State Sanitary Code for Food Service Esfablishments,1Q5 CMR 594.000. Please attaeh copies of certificaxion to this application. The Health Department will not use gast years'rernrda You must provide new eQgies and maintain a file at your establishmen� 1. 2. PERSON IN CHARGE: Each foad establishment must have at teast one Person In Charge(PIC)on site during hours of ogeration. 1. 2. ALLERGEN CERTIFICATIONS: AII food service establishments are reqtrired ta have at least one fult-time employee who has Atlergen certification, as defined in the State Sanitary Code far Pood Service Estabtishments,105 CMR 590.409(G}(3)(a). Please attach capies of certificatian to this application. The Heatth Department wiii not use past years'reeords. You must provisle new copies and maintain a file at your establishmen� l. 2. HEIMLICH GERTIFICATIONS: All food service estabiishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuuer on the premises at ail rimes: Please]ist yaur employees trained in anti-chaking procedures below and attach copies of emplayee certifications to this form. The Health Degartment will not use past years'records. You must pravide aew copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LaI3GING: I;IC�NSti REQtilRED FEE PERMtTl1 'LICENSE REQU(RED FEE PERMIT# LtCENSF:REQUIRED FEE PERtvitT# �O(�(,.��4—OO�I3 B&S S55� � CABIN S55 MOTEL $110 INN S55 GAMP $35 SWIMM[NG POOL$I ltiea t ' i LOD�'iE $55 TRAILER PARK 5105 WHIRLPdOL 5116ea �'�`I FQOD SE3tVICE: �� 1:[CENSE REQUIRED FEE PERMtT# :LICENS£REQUIRED FEB PERMIT# i.iGENSE REQUIRED �EE PEItMlT# 0-Ifl0 SHATS �123 ,CONTfNGNTAL $3S 3JON-PROPft' S30 �>f00 SEATS S20(i C.'OiNMON YIC. Sbp WHOLESAI.E S80 � —RESEB.KtTC,HEN S80 � RETAIL SERVtGE: LIC;�'NSEREQ�IIRED FEE PEL�M(T# LfCENSEREQU1Rf;➢ FEE PERMII'# I,ICENSEREQUJRED FEE PERMPI`# <50sq ft. $56 >25.00d.�{ft. 5285 VENDING-FdQQ S25 =<25.00Osq:R . $150 _FR(7ZEAtDESSERTS40 �TOBAC�O �11Q IMAME CHANGE: �t5 AMOIINT Dt7E = S 55.C� *"*"*PLEASE TURN OVER ANA COMPLETE OTHER SIDE OF FORM***** ADMIlYISTRATI�N Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmouth is naw reqttired to hold issuance or renewal of any license or pennit to operate a business if a person or company does not have a Certificate of Warifer's Compei�sarion Insuranc;e. THE ATTACHED STATE WCIRKER'S C�MPENSATION INS[JRANCE AFFIDAVIT MUST BE CCIMPLE'TED AND SIGNF•D,OR CERT.OF INSURANCE ATTACHED OR VdORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid pnor to rer►ewaT or issuanc�of your penniis. PLEASE CHBGK APPROPRIATELY IF PAID: YES NO MOTELS AI�ID OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANGY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be Iimited ta the temporary and short term occupancy,ordinarily and custamarily associated with mc�tel and hotel use. Transient accupants must have and be able to demons�ate tt�at they maintain a principal place of residence eIsewhere.Transient occupancy sha11 generalTy refer to continuous accupancy ofno#more thar►thirty(3fl)days,and an aggregate of not more than ninety(9�)days within any six(6)month peniod. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject ta the eolleetion of Room Occupancy j Excise,as defined in M.G.L.c.64G or 83Q CMR 54G,as amended,shall generaily be considered Transient. � PUOLS POOL OPENING:All swimming,wading and whirlpoois wtrich have been closed for the seasan must be inspected by the Health Departrnent prior ta opening. Contact the IIealth Department to schectale the inspection three(3} days prior ta ogening.PLEASE NOT'E:Peaple aze NOT ailQwed t�sit in the pool area unril the pool has been inspected and apened. POOL WATER TESTING: The water must be tested for pseudomonas,totai coiiform and standard plats cat►nt by a State certified iab, and submitted to the Health Department three(3)days prior to opening,and quarterly thereafter. POflL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('�days of closing. I i FOOD SERVICE SEASOI�AL FOOD SERVICE OPEIVING: All faod service establishments must be inspected by#he Health Degaztment priar to opening. Piease contact the Health Deparlment to schedute the iuspection three{3)days prior to openmg. CATERING POLICY: Anyane who caters within the Town of Yarmouth must notify the Yarmouth Health Degartment by filing the required Tempor�y Food Servioe Application form 72 haurs prior to the catered event. These forms can be obtained at the Health Department,ar from the Town's website at www.varmouth.maus under Health Department, Dawnioadable Fornas. FROZEN DESSERTS: Fmzen desserts must be tested by a State certified lab prior to opening and manthly thereafter,with sample results submitted to the Heatfh Deparnnent Failure to do so wiil zesuit in the suspension ar rev�ation of your Frozen Dessert Permit until the abave terms have been met. CIUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitertwaiiress service),must have prior approval from#he Board of Health. OUTD04R COOHING: Outdoar cooking,preparation,or display af any food product by a retail or food service establishznent is prnhibited. NOTICE:Permits run annually from January 1 to December 31.IT IS YOUR RESPONSIBII.TT'Y T'C?ItETURN THE COMPLETED RENEWAL APPLIGATION{S}AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FC►OD ESTt1BLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMEi�IT,ETC.),MUST BE REI'4RTED TO AND P OVED BY THE BC?ARD OF HEALTH PRIOR TO COMMENCEMENT. REN�VATIONS MAY Q A SITE PL i DAT'E: ��(T�—�� SIGNATURE: . PRINT NAME&TITLE: Rev.10/12/17 , t�"��: . �a. �h„� The Commonwealth ofMassachusetts ��-� � �x� 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 Anulicant Information Please Print Legiblv BusinessJOrganization Na.me:��.?'�',��ll��.� �� . Address• ��;' ,{!�/��'�i�%s f, City/State/Zip: � � Phone#: — —p Are yon an empbyer?Check tLe appropriate boz: Basiness Type(reqnired): 1.❑ I am a employer with employees(full and/ 5. ❑Retail �part-time).* 6. ❑RestaurantBaz/Eating Establishment 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. g. �Non-pmfit [No workers'comp.insurance required] 3.❑ We are a corporation and its officers have�ercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.�Manufacturing no employees.[No workers'comp.insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees.[No workers'comp.insurance req.] 12•�OtheT 'Any applicant that checks box#i must also fill out the secrion below sl�wing their workers'compensation policy inforn►a�i�. ssIf the coipo�ate officers have exempted themselves,but the coiporation has o�er employces,a workers'compensation policy is requiied and s�h an org�ization should check box#1. I am an e�nployer that is pr»viding workers'compe�rsation i�uurance for my employees. Below is the policy inforn�atior� ins�rance Company Name: Insurer's Address: CitylStateJZip: Policy#or Self-ins.Lic.# Expirarion Date: Attach a copy of the workers'compensation policy declaration page(showing the poli�.y namber aed eapiration date). Failure to secure coverage as required under Secdon 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fime_up to�1,SQ0.(I0.andlc��e�imprisnnment,-as-well as civil penalties iu the form of a ST�P��RK-Opn�u �na a� of up to$250.�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 verificarion. I do hereby ce ' , n the pa' and nalties of perjury that tke information prnvided above is true and correc� � Phone#: O,�`'tcial rrse only. Do�rot write in this area,to be compl�ted by city or town offrcia[ City or Town: Permit/License# Issamg Aut6ority(circle one): 1.Board of Health 2.Ba'iding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov�dia