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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH , APPLICATION FOR LICENSE/PERMIT-2019 •Pleasecomplete form and attach ail�►STdocum `RETURN "I .�.�'`• :s, M;i; . !3': . LL�tQTR'ALL B re to doTES i l ' CBNs Failure to do so will result m ", return ofyour application packet. ESTABLISHMENT NAME: crh y{.4$ uT f1 ./11e�i>/D • • 4Y'1711-��// LOCATION ADDRESS:fait dt/ �JAR/uOua A' AO/MAILING ADDRESS:�J`8/�. 1 1142$77 / E-MAIL ADDRESS:ML'D,r/ (QNI,I L. WM OWNER NAME:JAY _TINA n CORPORATION NAME, F APPLICABLE): TELit: .108 ,$D8-y 'y MANAGER'S NAME: gCOPC�E RRi, SSAA1� MAILING ADDRESS:3S/ &WW2 "`iP E7 N/ ifkk mouYH /ft Dab 9 3 POOL CERTIFICATIONS: tilted by State law. Please list the designated The pool supervisor must be certifiedssttardfit�ool��rthis foras m Pool Operators)and attach a copy • 2. m 1. C: ] Pool operators must list a minimum of two employees currently employee in standard First Aid and Comm Please list �� r �� one certified at all times. --i r Cardiae'Resuscitationtccopies oft,havingto this form.The Health Department will not use . G employees below and attach of their certifications years'records. You must provide new copies and maintain a file at your place of business p r.....1 Crn c., GJ 1. 2. - 56 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 in the State Sanitary Code for Food Service Establishments,105 CMR 590.000. Protection h copies, fs defined application.The Health Department wiU not use past years'records. 4 Please attach copies ofcxstificationtothis You must provide new copies and maintain a file at your establishment. Z. 2. 1. N PERSON IN CHARGE: IC site during hours of operation a 4'' Each food establishment must have at least one Person In Charge(PIC) ' 1. 2. ALLERGEN CERTIFICATIONS: to whohasAllerg�certification, All food service establishments are required to have at least one full-time employee as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records.Yon must provide new copies and maintain a file at your establishment 2. 1. HEIMLICH CERTIFICATIONS: trained in the Heimlich All food service with 25 seats or more must have at least one employee Maneuver on the premises at all times. Please list your employees trained in anti-chobelow and king i � attach copies of employee certifications to this form. The Health Department will not use pasty ,records. You must provide new copies and maintain a file at your place of business.1. 2. 3. 4. bo*,-I5-03b-0`4 RESTAURANT SEATING: TOTAL# bokre-(S-14V -O OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT If LICENSE REQUIRED FEE PERMIT Itmain FFEE PERMIT_ INN CAMP $55 ---SWR 1G POOL$110ee --�ioDCE $55s _ —TRAILER PARK. 51P 05 _WE $110ea. FOOD SERVICE: LICENSE REQUIRED =>100 SEATS PERMIT# LICENSE REQUIRED FEE PERMIT LICENSEFEE PERMIT i 0-1003S $125 _CONTINENTAL $35 _COMMON VIC. $60 $30 LRETAIL SERVICE: ICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT S >25,000 $285 VENDING-FOO f12255 = X11- $150 7 $40 TMEA -Y NAME CHANGE: $15 AMOUNT DUE = S 260.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""' . i 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 V NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient ocxupaocy shall be limitedto 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:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health . to opening. Contact the Health Department to schedule the inspection three(3)days prier to opening. ASE .Ley t :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 pones,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(T)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 , 7•._ the required Temporary Food Service Application form 72 hours prior to the catered event These forms can be ., , 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 the Health Department Failure tested byto do soe owill result or revocationed lab prior to openiqg and monthly � results with sample From 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 Boats 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 December31.ITISYOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATIONS)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR 'a a L (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED B�•`i BOARD OF HEALTH PRIOR TO COMMEN" / RENOVATIONS MAY REQUIRE A r- . DATE: /1 l%611 SIGNATURE: / PRINT NAME&TITLE: ✓fid 2 Ai AO 0 W4(t i Rev.lar23/111 l The Commonwealth of Massachusetts Department of Industrial Accidents 0. 14= � Office of Investigations 1 Congress Street,Suite 100 :1 Boston,MA 02114-2017. '`�1, www mass.gov/dia ! Workers' Compensation Insurance Affidavit: General Businesses Auolicant Information Please Print Legibly Business/Organization Name: c %r 114 Address: /o p As, � , , .,,,6%,6- i City/State/Zip: Phone#: (5S) ? -- 7S// Are y s r an employer?Check the appropriate box: Business Type(required): 1.[I I am a employer with j employees(full and/ 5. 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ 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.D Manufacturing no employees.[No workers'comp.insurance required]** 4.0 We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers'comp. insurance req.] 12.0 Other g ...S' S7f.7.1.0 *Any /1 '*Any applicant that checks box#1 must also fill out the section below showing their worlaers'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 ane an employer that is prang workers'compensation insurance for my employees. Below is the policy information. � e� Insurance Company Name: 11 //Va./AV/Val_7,0,iw z2."— 6.',`f GG i Insurer's Address: /$(21 gPn"�-e /'e City/State/Zip: .4// /V 34. //'Y �y &Z/3 Policy#or Self-ins.Lic.# *%9 33 Expiration Date: O.9/3o o ' Attach a copy of the workers'compensation policy declaration page(showing the policy number and ,kation 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 51,500.00 and/or one-year imprisonment,aswell-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,under the painspenalties of perjury that the information provided above is true and correct. ul_�� :: / D. ' /6Z- G Phone#: - 0.6-,2 c8-8) Official 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 aerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia