The URL can be used to link to this page

Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH co,iz APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessarydocuments by December NOTE:ALL BUSINESSESWITH LIQUOR LICENSES MUST RETURN FORMS BYNOVEMBER S • Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 57)9770N7tVe AIDC / L6%ICW7v1y SC/1t+3 L TAX ID: ~ LOCATION ADDRESS: a76 Sirfru4/A-Kciff TEL.#: c -760• ST400 MAILING ADDRESS: 'SO uTN y R/s1a tT71 v-i4 626hc, E-MAIL ADDRESS: POWLC (9,dy-Rec/,.ia4a.(• OWNER NAME: C -eot i.),IOl)RagAi - 5Lipc12iurCw'ott37' CORPORATION NAME(IF APPLIC` I E): )erv.vts 1/,q-2-rzsu Sc -fro Di 0)2tcT MANAGER'S NAME: Ron V Ey YUu/&l7 TEL.#: MAILING ADDRESS: 0994 4-VE leA,nu 77•! ;414 ij G 4/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary 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 provide 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 this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. /fl z%sc4 6A4 vi,e) 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 4l0 i cS/9 C/ t/iil) 2. ALLERGEN CERTIFICATIONS: 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,105 CMR 590.009(GX3)(a). 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 establishment. 1. 0-/SSA a/414-0N 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 use past years'records. You must provide new copies and maintain a file at your place of business. 1. /J4ai S.4 Gi-u14/50 2. 3. 4. RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 —SWIMMING POOL$110ca. _LODGE $55TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 � "/ —>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 FRdZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ WA/1/) 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 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.640 or 830 CMR 64G,as amended,shall generally 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 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 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.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 Health Department. Failure to do so will result in 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 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 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 TO COMMENCEMENT. RENOVATIONS MAY REQJ A SITE PMN. DATE: 1(7261/( SIGNATURE: /tp.Q„i3O PRINT NAME&TITLE: �00l1(�UW ROO 5#-V't ' a2tt..-70R— Rev.10/13/18 • The Commonwealth of Massachusetts Department of Industrial Accidents E-;y7 ;� t P Office of Investigations =�;' • 1 Congress Street,Suite 100 6• Boston,MA 02114-2017. - www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:_Dennis-Yarmouth Regional School District Address:296 Station Avenue City/State/Zip:S. Yarmouth, MA 02664 Phone#: 508-398-7610 Are you an employer?Check the appropriate box:- Business Type(required): 1.g I am a employer with 3 employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2. I am a sole proprietor or partnershipand have no 7. ❑ Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment theirright 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, with no employees. [No workers' comp..insurance req.] 12.)2 Other .54-ioct, b i J 7?Z i T' *Any-applicant that checks box 51 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 required-and such an organization should check box#1-. I am-an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Midwest Emplovers Casualty Insurer's Address: 14755 N Outer 40 Rd # 300 City/State/Zip: Chesterfield, MO 63017 Policy#or Self---ins.Lic.# EWC006911 Expiration Date:, 7/01/2019 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 certify,unde a pains a 1L) ties of perjury that the information provided above is true and correct. Signature: etrixe,. Date: ll1/416 Phone#: 6de- 393-- Official 93Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Midwest Excess Workers'Compensation Binder Ernpyer Casualty ri.erwk-v itlatArgiq twildw*st Eittprovers Casualty Company Insured: prenella Yemioultt Regiort24 School District P011icy Number; EViltattmiell Effective Oats: OVA/20118 Quote Number: iniskto ExiathAttort maw O7fti1f201S. Named Sts : Allas,sachusetb-s $ervice Cony: Cook&PompriY. Box TO Mirhfi MA02.0a04038 Cat??i3es'the P orserniln* laae wikchBd) g_effej;F:C: SpeOfic Unit STAIIUTORY •Soacido Retantion: S450.000 rtillua: Employers Liability Lknit: 51,000,0013 Amrvate Limit Sa,Goo,oce kigeresite ReterAon{Rote as s Pe-roontage of Ronnal 293.0ti% MmPro Aggreg4e Retention: 850,051 Aggregate Loss Limitation: $451),C00 fRATIV.;&AgE; Polioy Estimated PayrolL S32,65140.0 POIcy Eslirralled Wartar Poky Estirmetari NA Per C.,*12: NA Policy Normal Premium: s2a5,9a) Rale as a Pen:alb:age of NorraV Premium: 1525% PREUVM: Total Es1intste0 Policy Premium tindudinil fiat charges): $114..5c2 Paw hCaelnurti Prermon: $40,088 ElaPosk Prernium: 5,44„542 D:4-403iE Flat Ch ): ip.A! $414,642 Terrorism Risk insurammkg Of 2002: cricluded Tole!Deposit DUB above) /43(.44,g, 0610,8a018 Mid trnbloyeas Cemally Dela 21X101 B34 yot : rriptloyers Ccuucuil Endorsement Schedule t Binder Ins2urer, *de4 Egrocrem Casualty Conwrry. FH ey Effective Date: 071a112;018 In5ured: Destria Yarmouth-Reichal School Distil Pax-y, !Mk-Oration Date; cY7FJ1120itat Policy EIROM391t &Rev iodugdes the flownci gLcli 01-gamy...pits: Ameridnamt to Schedule.[tem 11 CMEI-1 97 Policyholder 0. clucttre Notice of Telroristn Insmnoe Rage t of 1 Date Prinbat Co9/0811..01U JENS,