HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTII BOARD OF HEALTtf
APPLICATION FOR LICENSE/PERMIT-3019
Mr-, *please....edam form:32( attach all 4 v.. nn documents ..)...„,....1„es.,r r
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Failure to do so will '' t return o your applieation pocket
ESTABLISHMENTNAME: t. ,, t :t L. :.A ‘,.... :c_ .,; TAX Ell
LOCATION ADDRESS: 7/3 r' a;u. S& L R.41- — 5r) TEL.*: f 0 it - ics 414- '7 g 6
MAILING ADDRESS: 10 5 t ic>., rti3 '�Cv.. s t- r Z u 4 ,,1 I. ft t`k d
E-MAIL ADDRESS: Cl(peS o c L... ". . C m . w_
OWNER NAME: .....f5. -..,...,:40- '. 'Sf� p
CORPORATION Il APICABI.E)' ._ a, _. i1 a c 1 r a
MANAGER'S NAME:� I a w TE .# 0 .- . ' 4- oa 6
MAILING ADDRESS: - s L.' 4;f*,:v. S. A v, ` t /ma„, fifi O2.. -+
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool r(s)and attach a copy of the 4--, ification to this fes.
1, c i r'f ' 2 —^ o
cued in standardFirst Aid and Community D Q. Fl
Pool rr
operators list aminimum of two employeescurrentlyr ;)
CardiopulmonaryResuscitation(CPR.) havingone certified employee on premises at all times. Pleaselist the 6 r
employees below and attach les of ficati to this num.The Health Dep t ent will not past = crs 1
years'records. You must provide new copies and maim a file at your place 000f bsrnineas.. 0 rte, c
3. 4.
FOOD PROTECTION MANAGERS-CERTIFICATIONS:
All food i establishments are required to have a least one full-time employee who is certified as a Food
Protection ,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, 2
You must provide new copies and maintain a filar at your establishment. 9
a
I, 2. -10 15)
PERSON IN CHARGE:
Each food establishment must have at leastone PersonIn Charge(PIC)on site during hours of tion.
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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 ice Establishments,105 CMR 590, G 3 Xa). Please h
copies ofcertification to this application. The Heath s ,,.rtment will not use past 'records. You must
provide newies and maintain a file at your establishment
1. ilk 2.
HEIMLICH CERTIFICATIONS: �ieh
AR food service establishments with 25 or must have at least employeeiie1 below and
Maneuver on the premises at all times. Pleaselist t,l l c trained in ami-ch : procedures
,ach copies of employee certifications to this loon.'Thee Department will net use past years'records.
You must provide new copies and maintain a file at your place of business.
1. /,` 2.
3 4, v
RESTAURANT SEATING: TOTAL Ai/A -
OFFICE USE ONLY
LOGGING! Id
LICENSE REQUIRED D 1 EE PERMIT# LICENSE REQUIRED PERMIT# LICENSE REQUIRED MOTEL IQ PERMIT
SI $55 5 M a
-CAMP SWI POOL
WHIRLPOOL $110e.
FOOD LVICCE:
LICINSE 1311OIRZYJ FEE MOOT 1 LICENSE .i r ► FEE PERMIT# LICENSEREQUIRED PERMITS
0-100 SEA. 5125 ,LCO i AL' $35 _ 14-DPI SAf $3$0 0 ._.
>IOO SEATS V200 COMMON SIG. &d ,.....RESTD:KITCHEN$80
RETAIL Vi `
LICENSE nit,
P # LICENSEREQUIRED T# 1 LICENSE REQUIRED PERMIT#
<50 FOOD$25
' <25,000 all, $150 ..,"" O�000�i lt T$40
a+t7e circa; $15
AMOUNT HUE w S "
*****PLEASE TURN OVER AND coati/arra<mitacoati/a SIDE OF FORM*****
ADMINISTRATION
Under Chapter 152.Section 25C,Subsection 6,the Tower of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business ifs pawn or company does not have a Certificate of Worker's
Compensation Insurance, THE ArrAmEn STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT OF INSURANCE An:Au-LED
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 Motelor Hotel use,Transient occupancy v I be limited to
the temporary and short to occupancy,ordinarily and customarily associated with motel and hotel use. Tmostent 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 of not more than ninety(90)ems
within any six(6)month period. Use of 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.01.c,640 or 830 CMR 640,as
amended,shall generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been c ••• for the season must be .., by the
Health Department prior to opening. Contact the Health a 4 tilt t to sehedele the hispeetion three(3) a ye prier to
opening.PLEASENOTE:People are NOT allowed to sit in a 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 Stair
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:
MI food service establishments must be las by the Health # -et prior to opening. Please contain the Health
Department to schedule the inspection three(3)days prier to opening,
CATERING POLICY:
Anyone who eaters within the Town of Vermouth must notify the Yarmouth Health Department . the -0 'rod
Temporary Food Service Application form 72 hours prior to the entered event These forms can beat the
Department,or from the Town's website at .Aunder Health Department Downloadable Forma,
FROZEN DESSERTS;
Frozen desserts mint be tested by a State certified lab prior to opening and monthly thereafter,with sample results animated to
the Health 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(Le.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Beat&
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, 400 the tobacco license cap is reduced.
NOTICE:Permits run annually from January 1 to December 31,IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLEIED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2013.
ALL RENOVATIONS TO ANY FOOD IMABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COlvIMENCE1HENT. RENOVATIONS MAY REQUIRE A SITE PLAN,
2111- I
DATE:
SIGNATURE: S 1 •
er3
PRINT NAME&t TITLE:_ 4 # Pt c
Rev Unlit*
TRANSIENT OCCUPANCY: For purposes of the!imitations 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.O.L.c.64G or 830 CMR 64(1,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 Deportment 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 root,SERVICE OPENING:
All food service establishments must be inspec,.* by the Hearth 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 wwwjarmcothroa.us under Health Department,Downloadable FortrIS.
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 wits 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 Ito December 33. 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 REQUIRE A SITE PLAN,
DATE: 2--/2---14/ SIGNATURE: 5.1'
PRINT NAME&TITLE: K.4kt 40
Rev.10/23/13
I^' Dear nt of industrial Accidents
. , . .,. Office ".Investigations
° 1 Congress Street,Suite 100
0: 'Taili:ar 1 Boston,MA 02114-2017
www,inass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly=_
Business/Organization Name: ,t k ,. _.._ o c p` ,
Iti
- .6 � t/ tit
...w. t9/ `
.. 3 Address: Z-42-447
City/ State/Zip: c.. \ , . v., 0 ( Phone . 17 4,36' �73
Are you an employer?Cheek the appropriate box. Business Type(required):
1.0 [ arra a employer with _ employees(full andi
5. 0 Retail
or part-time):* 6. E Restaurant/Bar,Eating Establishment.
2.7A 1 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] ' caa profit
3.0 We are a corporation and its officers have exercised i 9, 0 Entertainment
their right of exemption per c. 152,§1(4),and we have 1 10.0 Manufacturing
cturing
no employees. [No workers' comp,insurance required]' ° l 1. Health Care
4,0 e are a non--profit organization,staffed by volunteers, /
with no employees. No workers` comp. insurance req.j 1 1151 Other fl at '•-
"Any applicant that checks box{tl must also fill out the wctier below shou-int their workers'ezrmpensetton policy information
4*Tf rite corporate officers have exempted themsela es,,but the corporation has other employees.a workers'compensation pulley is requared and such an
organization should check box#1.
I am an employer that is providing rworkel 'compensation insurance for my employees. Below is the policy information.
Insurance Company Name;,. . .
Insurer's Address:
City/State/Zip: _......
Policy 0 or Self-ins, Lic. �..._Expiration Date:
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 ar dior 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 DR for insurance coverage verification.
I do hereby certify;under the pains and penalties of perjury that the information provided above is true and correct
e f, ature ., l r 11 Cg7v--- Date: rte- / !
- FS
hrat ` . x` � . _� __. w ___..,...M..
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):
I. Board of Health 2.Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6. Other
Contact Person: Phone#
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