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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSEIPERM1T-2019 *Pleaseennwlea form and attach allnecessary documents by kiwi',kgalaiji. .!!.L WITH RLICB11�4 ►S ISTREITIE I� Faihlrs to do so will nreturn of your application packet. ESTABLISHMENT NAME: C4, - 16o Convene i.i - TAX ID: - LOCATION LOCATION ADDRESS:S• i.o.bq Q.,d .•11- TEL.#: 5 a Y L S Y G ti 69 MAILING ADDRESS: " E-MAL ADDRESS: Ccc•nvtv►ie,)cc ( lee+1,40• r•a., OWNER NAME: 1451,t K ti a•ft CORPORATION NAME(IF APPLICABLE): N ••r..,.. „Ty)c. MANAGER'S NAME: /43 K TEL#: MAILINGADDRESS: 3°1 I',cram., 1..a,. . Ya rAL vat/ MA- ot.66,y > c-} Gnu POOL CERTIFICATIONS: The peel supervisor must be certified as a Pool Operator,as required by State law. Please list the designated = wfia Pool Operator(s)and attach a copy of the certification to this form. m o 1. 2. oo Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation.(CPR),having one certified employee o premises at all times. Please list the employees below and attach copies of n certifications to this form.The Healtht will not use past years'records. You must provide new copies and maintain a file at your place of b or 1. 2. 3. 4. , .o 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=obtain a file at your establishment. 1. 2. .;. PERSON IN CHARGE Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1, 2. ALLERGEN CERTIFICATIONS: i 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, 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 coiges 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-choking procedures below and copies employee certifications to this form. The HealthDepartment will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �0( F-(5"-160 —0Li 1345 w-ri)-tom-1(c. -64 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT 0 LICENSE REQUIRED FEE PERMIT S BOB S55 CABIN $55 MOTEL $110 —INN $55 CAMP $55 SWIMMINGPOOL$IIOa, Ss5 —TRAILER PARK $105 _WHIRLPOOL $110a. FOOD SERVICE LL( ISE REQUIRED FF E PERMIT/ REQUIRED FEE PERMIT M LI RED FEE CONTDRINFAL 535 PERMIT S >10000 SEATS 5200 COMMON VIC. 560 WHOLESAI E It RESID.KITCHEN St0 RETAIL SERVICE: LICENSE REQUIRED FEB PERMIT S LICENSE REQUIRED FEE PERMIT M LICENSE REQUIRED FEE PERMIT<50 6 I<255,0000•q.a1'E. 5150 -u3eCR Nit. 550 .000NDRESSERT 540 'T52115 OBBNDACCO 51u105 NAME CHANCE: 515 AMOUNT DUE - S Ve0.00 *****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 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 permits. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe 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.640 or 830 CMR 640,as amended,shall generally be considered Transient POOLS POOL OPENING:AU swimming,wading and whirlpools which have been closed for the season must be' by the Health Dessert prior to opening. Contact the Health Department to schedule the bespectlo.three(3)days prior is 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 fortout coliform and standard plate count by a State certified lab,and submitted to the Health Department three( )�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 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 die Temporary Food Service Application form 72 hours prior to the catered event These forms can be au at the Department,or from the Town's website at wwwyamouth.aa.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 saapple results submitted to the Hearth Department. Failure to do so will result m 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 have prior approval 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. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits nm annually from January 1 to December 31. ITIS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. 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 i TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: h/10 r SIGNATURE: PRINT NAME A TITLE: Q hoc ) Ler. (Pre-r%Ayr) R .102311$ The Commonwealth of Massachusetts —— Department of Industrial Accidents _'. Office of Investigations -= • 1 Congress Street,Suite 100 Boston,M4 02114-2017. www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print]Legibly Business/Organization Name: C4 c ,,t,• c� N•tir 4h Adder: so L.ti (3'4 4.A Dr,'e_ 4.t ' City/State/Zip:So A'� Y��►.' t Al oz.(64 Phone#: 8 - zS 7 0 4`i Are you au employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with employees(full and/ 5. ®Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. Q Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. Q Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]"# 11.❑Health Care 4.0 We are a non-profit organization,staffed by volunteers, 12.0 Other with no employees.[No workers'comp..insurance req.] *Any applicant that ehedrs box#1 must also fill out the section below showing their workers'compensation policy information. "If the oorporale officers have exempted themselves,but the corporation has other employees,a workers'oompensadon policy is requited and such an organisation should Brock box#1. lam an employer that is providing workers'compensation ice for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy samba'and expiration date). Failure to secure coverage as required under Section 25A of MGL a 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. Ido hereby catifj+,under the pains and penalties of perjury that the information provided above is true and correct. Signature: i�� Date: 11-I t)i S Phalle#: $° - 2 4v — sr Oficial use only. Do not write in this area,to be completed by city or town of icia[ City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board S.Selectmen's Office 6.Other Contact Person: Phone#: www.mw.#ov/din