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Home My WebLink AboutApplication and WC r � TQWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2018 '"' *Please complete form and attach all necessary documents by December IS 20I7. Failure to do so will result in the return of your applicat�on pac et. ESTABLISHMENT NAME: G A ✓/f� ' LOCATION ADDRESS:�/' �7 I�''�slE�l�✓ �I V� TEL.#: '�OB'7GI -OG.'IJ MAILING ADDRESS: �t �I �' • �¢.4A�o vTi�/ /J7A ��T GG'f� E-MAIL ADDR�SS:�fuE�� /YlAC.t.�i"�i�e d/s��s• ��''� OWNER NAME:��iw/ l�j�.eA�____ �c�•��ry G s�r/t'� CORPORATION NAME(IF APPLICABL$):t�d� � �' �� MANAGER'S NAME: R•t.L •r TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: = 0 � The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the designated frt � � Pool Operator(s)and attach a copy of the certification to this form. —ri N � l._ 2. = UJ Pool operators must list a minimum of two employees currently certified in standard First Aid and CommuniTy � � � Cazdiopulmonary 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 will not use past years'records. You must prov�de new copies and maintain a file at your place of business. 1 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 t�is application. The HeaIth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. . � 1. 2. �,.,,�.,. a PERSON IN CHARGE: �`�'' Each food establishment must have at least one Person In Charge(PIC)on site during hours of operafion. �"• 1. 2. � ALLERGEN CERTIFICATIONS: All food service establisl�ments are reqwired to have at least one full-time employee who has Allergen certification, as denned in iiie Siace Sanitary i,ode far Food Service�stabiishments,i05�MR 594,i�09(G)(3 j(a'). 3 iease at[ach . copies of certification to this application. The Health Department witl not use pasf years'records. You must provide new copies and maintain a file 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-chokmg procedures below and ' attach copies of employee certifications to this form. The Health Department will not use past years'records. i You must provide new copies and maintain a file at your place of business. i ! 1. 2. 3. 4. RESTAURA�'T SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT 1t LiCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 ' LODGE S55 ,TRAILER PARK $$OS _WHIRLPOOi OOL$�l�O�ea. , — �t��-��f-05?2 fFO'JID SERVICE: � �4 t � � LICENSE REQUIRED FEE PERMI'C# LICENSE REQUIRED FEE PERMIT tt LtCENSE REQU[RED FBB PERMIT# 0-IOO SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 �� —>100 SEATS 5200 _COMMON VIC. $60 ��DE�TCHEN $80 �2 RETAIL SERVICE: LICENSF,REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERM7T li LICENSE REQUIRED FEE PERMIT# <50sq it. $50 >25,000 sq.ft. 5285 __ VENDING-FOOD S25 —<25,000 sq.fr. $150 =FROZEN DESSBRT $40 =TOBACCO SI10 NAME CHANGE: $15 AMOUNT DUE = S W��.___.. *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"***` 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIG�tED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S CONvIP.AFFIDAVIT SIGNED AND ATTACHED�C_, Town of Yarmoixth taxes and liens must be paid prior ta renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO MOTELS Al'�D OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be iimitea to the temporary and short ternioccupancy,ordinanly and customarily associated with motei andhotel use: Transient occupants must ha�e and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 generaliy refer to continuous occupancy of not rnore 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,sha11 generally be considered Transient. POOLS POOL OPENING:Ail 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"1'E: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 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 OPETTING: All food service establislunents must be inspected by the Health Department prior to opening. Please contact the Hr;�u'�"De�mznt tu s�h�uic wie iasyecti�rn cnree{:i1 days prior to.�per;ir�g. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed 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 Healfh Department. Failure to do so will result in the suspension or revocarion of your Frozen Dessert Pernut 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 Boazd of Health. OUTDOOR COOKING: 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 YOiJR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. � ' ALL REI�10VE1"iIi1NS T`U ANY"�tldD ESTABLISi-�MEN�', MO'i'�L t3R �OL (i:�., PA'R.+� �� G, NEW EQtTIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVA7'IONS MAY REQUTRE A SITE PLt�N. DATE: SIGNATURE: PRINT NAME&TITLE: x�.ionvt� � Tlae C� ��a�e�l£h �f°��cla��e�� I1��t �c��f fr�c�r.��r�r�l.A.c��n�s Qf,fice of drivestigatt�ns 1 ��n��s��,�a�afe 1�Q �oston,l�rt4 0�114-20��. � svww.�zass.gov/dia �Vorkers' Compensahon Insuranc�Affidavit: General��asinesse� Apr�licant Information Please Print Le�iblv �� '✓� c R�� usiness/Organization IVame: �o� �� a�cde�o E o�e �'�o v�,s'o� Address: �/- � ��-9� �''� �'• ` A �s� � �� .�rl� �� r � City/State/Zip: � � Pho�e#: ,��- 7 G� � �' �.� � . Are you an e�ptoyerY Check th�a�propriat�bo�: Iiusiness T�pe(required): 1.(� I am a employer with�employees(full and/ 5• ❑�Zetail or part-time).'i 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � O�ce and/or Sales(incl.real esta4e,auto, etc.) employees working for me in any capacity. �NO WOY'iCeYS' comp.insurance required] �• ❑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 10.�Manufacturing no employees.[No workers'comp.insurance required)� 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, �� ,� with no employees. [No workers' comp.insurance req.] 12.�Other *Any applicant that checks box#1 must also fill out the secrion below showing their workers'compensarion policy information. *�If the corporate officers have exempted themselves,but the oorporation has other employees,a workers'compensation policy is required and such an organizauon should check box#I, I am an employer that is providing workers'comperesation insuraatce for rny employees Bedow is tdae policy anfora�tatiori. Insurance Company Name: � � ��-�`� ✓��• Insurer's Address: �10 � �°e� �''J �� `�� °�" City/Sta.te/2ip: �[/o�a/C Y �9 �`� � � 4 � PoIicy#or Self-ins.Lic.# ��`�� Expiration I3ate: �� " l`�� 7 ' Attach a copy of the�vorkers'compen�ation policy declaratioe�p��e(shasving the policy number and eapiration date). i � Failure to secure coverage as requireci under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a i fne up to�1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.40 a day against the violator. �e advised that a copy of this statement may be forwarded to the Office of _ ; Investigations of the DIA for insurance coverage verification. I a►cr kereby certffy,under the pains�and pen�lties of'perjury tdaat tdae in,fora�aatio�a p�ovided above is erue rand correct. Si ature: Date: �o `� � ' �'� Phone#• `�� Q� ��'�� Officaal use only. Do not write in this area,8o be cotnpleded by cify or town offacia� Cify or Town: � Permit/License# � -_ _ . _ __ --- _ __ _ __ __ Issning Authority(circle one): 1.Soard of Health 2.Bnflding Department 3.City/Town Cderk 4.Licensing�oard 5.Selectmen's Of�ace 6.Other Contact Person: Phone#: www.mass.gov/dia � ,