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Home My WebLink AboutApplication and WC1 i j � TOWN OF YARMOUTH BOARD OF HEALTH I �� APPLICATION FOR LICENSE/PERMIT-2018 'I ` *Please complete form and attach all necessary documents by December 1 S 2017. Failure to do so will result in the retum of your applicahon pac et. ESTABLISHMENT NAME: "� `M � LOCATION ADDRESS: '1 TEL.#: ' �{'��p MAILING ADDRESS: E-MAIL ADDRESS: � 0 •GO Y'� OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: �,p11'L: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS; The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated �= O � Pool Operator(s)and attach a copy of the certification to this form. r:; � � `-i ta? 1. 2. - &�"1 ''- O Pool operators must list a minimum of two employees currently certified in standard First Aid and Community n N "`= Cardiopulmonary Resuscitarion(CPR),having one certified employee on premises at all times. Please list the -U a �;� employees below and attach copies of their certifications to this form.The Health Department will not use past -� —j C,�f years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. �.� FOOD PROTECTION MANAGERS-CERTIFICATIONS: �.. All food service establishments aze 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 establishmen� i. 2. �'. �� PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �' r�� j 2 �`�� __�'� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-rime employee who has Allergen certificarion, as defined in the State Sanitary Code for Food Service Establisiunents,105 CMR 590.009(Gx3xa). 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 est$blishment. L 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 nse past years'records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4- RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED PEE .PERMIT# UCENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FEE PERMIT# B&.B S55 CABIN S55 _MOTEL 5110 INN S55 CAMP S55 _SWIMMING POOL S110ea. LODGE E55 _TRAILERPARK $105 _WHIRLPOOL S110ea. FOOD SERVICE: UCENSE REQU►RED FEE PERMIT# L[CENSE REQU[RED FEE PERMIT# I.ICENSE REQUIRED FEE PERM►T# 0-100 SEATS 5125 _CONTINENTAL S35 NON-PROFIT S30 —>100 SEATS 5200 COMMON VIC. S60 WHOLESALE S80 ��/'� — �-RESID.KITCHEN S80 `'� RETAIL SERVICE: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25,000sq ft. 5285 VENDMG-FOOD S25 —<25,000 sq.ft. 5150 —FROZEN DESSERT S40 _TOBACCO 5110 NAME CHANGE: S15 AMOUNT DUE _ $ PA��D **'"*PLEASE TURN OVER AND COMPLETE OTHER 51DE OF FORM*'"** �o�-l�-ooS 3�l � 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 SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your petmits. PLEASE CHECK APPROPRIATELY IF PAID: / YES �/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIEN'I'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 genetally 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 aze NOT allowed to srt 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 paol 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 Department 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.yarmouth.maus under Health Deparhnent, 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 Department. Failure to do so will result in the suspension or revocarion 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 have prior appmval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pemuts 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 FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE A SITE P N. DATE: (� SIGNATURE: PRINT NAME&TITLE: R�.�onui� � The Commonwealth of Massachusetts �'�� Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance�davit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: V� 101�(�Y °�v' id)�Q('�5 Address:��DIT11�(/1r �'�Dlll'l�� City/State/Zip: . QYY^c1�� Phone#:��$� (.Q�I`��4'�lf Are you an employer?Check the appropriate bog: Business Type(reqnired): l.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or paztnership 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• �on-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]* 1 LQ Health Care 4.[r� We are t organization,��lunteers, ' no employees.[No workers'comp.insurance req.] 12•0 Othe�' *Any appli 1 must also fill out the section below showing their workers'compensation policy information. *'If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my emp[oyees. Below is the policy inforn�ation. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of t6e workers'compensation policy declaration page(showing the policy number and eapiration 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 p ' and pen ' of perjury that the information provided above is true and correc& , Si ature: Date: Phone#: — O�cial use only. Do not write in this area,to be completed by city or town oj�cial City or Towu: Permit/License# Issaing Aathority(circle one): 1.Board of Health 2.Building Department 3.City/1'own Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Peison: Phone#: www.mass.gov/dia