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Home My WebLink AboutApplication and WCI � � TOWN OF YARMOIJTH BUARll OF HEALTH 3 � APPLICATION FOR LICENSE/PERMIT-2018 *Please complete form and attachall necessary documents by December 15 ZOU. � Failure to do so will result in the return f your application pac ct. ESTABI.iSHMENT NAME: Q' C : - �� LOCATION ADDRESS TEL.#: �bD - ✓� / 9� MAILING ADDRCSS: F.-MAIL ADDR�SS• � _ � OWN�R NAM�: CORPORATION NAME(IF PLl ' LE): �� MANAG�R'S NAME: TEL.#: D • �/�� MAILING AllUKESS: � POOL CERTIFICATIONS: The pool supervisor must be certificd as a Pool Operator,as required by State law. Plcasc list the designated Pool tor(s)and attach a copy of the certification to this form. { � O ; 1. 2. � � °�."• � Pcx�l operators must list a minimum of two employees currently certified in standard First Aid and Community -�i N �' � Cardiopulmonary Resuscitation(CPR),having one certified cmployee on premises at all times. Please list the -� � ,r��,,, � employees below and attach copies of their certifications to this form.The Health Department will not use past � � �; � years'r rds. You must provide new copies and maintain a fde at your placc of business. �� cti �,�� 1. fr '^l ' 2. � � �� 3� 4- i FOOD PROTECTION MANAGF,RS-CF,RTiPICATIONS: � s=�-�� j All food service establishments are required to have at least onc full-time employee who is certiGed as a Pood �� Protection Manager,as defincd in thc State Sanitary Code(i�r Fqod Service Establishments, 105 CMR 590.000. Please attach c;opies e�f certitication to this application. The Health Department will not use past years'records. iYou mu t provide new copies and maintain a file at your establishment. � '�� 2� ..�Y;� � PERSON IN CHARUE: a"""��',,� Each food establishment must have at least one Person In Char�e(PIC)on site during hours of operation. � ` -� ' �' '::� 1.�� , 2. . Ai.i.F,RGEN CERTIFICATIONS: ; All food service establishments are required to have at least one full-time employee who has Allergen certification, ' as detined in the State Sanitary Code for rood Service Establishmcnts,105 CMR 590.009(G)(3)(a). Please attach { copies of ccrtification to this application. The Health Department will not usc past years'records. You must provide new copies aod maintain a�le at your establishment. 1. �/� 2. IIEIMLICI�CERTIFICATIUNS: 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 traineci in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'records. You mus provide new copies and maintain a file at your place of business. � 1. 2. i 3. 4. RF,S1'AUlU1N'1'SEA"fINU: "1'07�AL#t �� OFFICE USF.ONLY LODGING: LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRF.D FF.F. PF.RMIT N 1.ICF.NSF.RFQUIRF.D FF.F. PFR IT N � B&B $55 CABIN $�5 1 MOTF.I. $110 ,��G INN S55 CAMP $55 SWIMMING POOL SI l0ea. LODGG S55 TRAILER PA2K SI05 WHIRI.POOL $I IOca FOOD SERVICE: UCENSE REQUIRED F�t; PERMI'1�# LI(;E:NSk:Kt:QU1REU h't� N�KMI'1'# LICENSE REQUIRED FEE PERMIT# 0-I00 SEA7'S 5125 _CONTINF.NTAI, $35 NON-PROPI'1' E30 �IOOSEATS 5200 COMMONVIC. � WIIOLf•,SALE $80 —RIiSID.KITC}IEN $AO RF.TAtL SEItY10E: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LtCF,NSF.RF.QUIRF.D FF.F. PF.RMIT# <50sy.11. S50 >25_OOQ sq.ft. $285 VENDING-FOOD S25 —nS,fNN)sq.ft. SI50 _IROZGNDESSGR7' S40 _'IOBACCO SI10 NAME CHANGE: S15 AMOUNT DUE _ $ J I D.QO *•**"'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*4** 1�0�Ll5�-!2�?-0� � ADMINISTRATION Under Chapter 152,Secrion 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or rencwal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensatian insurance. THE AT"I'ACHED STATE WORKER'S COMPENSATION 1NSUltANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSUItANCE ATTACHED ' OR ; WORKCR'S COIvIP.AFFIDAVIT SIGNED AND ATTACHED � � Town of Yarmouth ta�ces and liens must bc paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO � MOTELS AND�THER LODGING ESTABLi5H1NENTS j TRANSIENT OCCUPANCY: Far purposes of the limitations of Motei or Hotel use,Transient occupancy sha(1 be ' limited to the temporary and short tertn 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 occupar►cy shall generally refer to continuous occupancy of not more than thirty(30)days,and " an aggregate of not more than ninety(90)days withu►any six(6)month period. IJse of a guest unit as a residence ar � dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Uccupancy Excise,as defined in M.G.L.c.64Ci or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS i � POOL OPErTING:All swimming,wading and whirlpools which have becn closed for the season must be inspected ' by the Health Dcpartment prior to opening. Contact the I teaith Department to schedule the inspection three(3) ! days prior to opening.PLEASE NOTE:People arc NOT allowed to sit in the pool area until the pool has been { inspected and opened. 3 POOL WA7'ER TESTING: Tlte water must be tested for pseudomonas,totai coliform and standard plate count by a Stale certitied lab,and submitted to the Hea(th Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSINC:F,very outdoor in ground swimming pool must be drained or covered within seven{7)days of closing. � FOOD SERVICE SEASONAL FOOD SERVICE OPENiNC: All food service establislunents 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 ea#crs within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requ�red Temporary I'ood Service Application form 72 hours prior to the catered event. T'hese forms can be obtained at the Health Department,or from the Town's website at www.�arcnouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSF,RTS: Frozen dessert.s must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the F�ealth Department. Failure to do so wiil result in the suspension or revocation of your Fmzen Dessert Pennit until the above terms have been met. OUTSIDE CAFES: 1 Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boarci of Health. ! OUTDOOR COOKING: Uutdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICF,:Permiis run ann�ally from January 1 to December 31. IT IS Y(JUR 1tESPONSIBILTI'Y TO RET'IJRN THE COMI'LE'TED RF.NF,WAi,APPLICATION(S}AND REQUIR�D PEE(S)BY DECEMBER 15,201'7. ALL RENOVATIONS TO ANY FOOD ESTABLTSIIMENT, MOT'EL OR POOL (i.e., PAIN'TING, NEW EQUIPMENT,ETC.),MUST BE RF.PORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMEN'T. RENOVA'�'IONS MAY UIRE A SiTG PL DATE: /�_! � SIGNAT � � PRINT NAME 8c TITLE: D �.- x�.iai2�i� 1 � T'he Commonwealth of Massachusetls Print Farm 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 � A�alicant Information Please Print Legiblv Business/Organization Name: ,�°� Q ��; -�� Address: �g�_�v� �� ; City/State/Zip: i o,ei,� Phone #: Us Q� 2�/—/9�� Are you employer?Check the appropriate boz: Business Type(required): 1. I am a employer with_�employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantJBarJEating Establishment 2.❑ I am a sole proprietor or parinership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) ' employees working for me in any capacity. ; [No workers' comp.insurance required] g• ❑Non-profit ; 3.❑ We are a corporation and its officers have exercised 9. ❑Enterta.inment ` their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing ! no employees. [No workers' comp. insurance required]* � 4.❑ We are a non-profit organization,staffed by volunteers, 1 l.❑Health Care ', with no employees. [No workers' comp.insurance req.] 12.�er �D',� � *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. "'If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is requ.ired and such an orgaui�tion should check box#1. j I am an employer that is pwvidin workers'compensation insurance r my employee� Below is the policy information. { Insurance Company Name: ,��j/`��/°S �S I � Insurer's Address:��'�� City/State/Zip:�.��Q/,�� L��j� � ; j Policy#or Self-ins.Lic.# �� /� ��G�19S�4�^�-/� E�iration Date: � d Attach a copy of the workers' compensation policy declaration page(showing the policy number nd piration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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 verification. � I do hereby certi , under the pains and pen ' s �erjury that the-information provided above is true arcd correct Si tur Date: � Phone#: os��' '��-1�� D,f�cial use only. Do not write in this area,m be completed by city or town o�'f'icial ! City or Town: Permit/License# Issaing Aathority(circle one): 1.Board of Health 2.Bnilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmeds Office 6.Other Contact Person: Phone#: www.mass.gov/dia