HomeMy WebLinkAboutApplication and WC 'r TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSEMERAIIT-2020
_ _ *Please complete form and attach all necessary does by Disier 13.2011.
False to do so will resuhinthe awn ofvour
NOTIfr AL SUWON=IIPM11.01101 LLICZNIES MOST Ir.
ESTABLISHMENT NAME: . . S Al ...e- , ! g • $r
LOIL LOCATION AADRE33; '/r �jf Sit Tr'Age, - i,r TEL# ,7g-- •9Cila
E-MAIL ADDRESS:
OWNER NAME: br � 4:t i krorjogr:
CORPORATION NAME(IF
MANAGER'S NAME: —7/t91‘111( Je t .f/1? TEL.#:rre '=
MAILING ADDRESS: s-IArrip-
POOL CERTIRCATIONS:
The pool supervisor must be awtified as a Pool OperMor,as required by State law. Please In the designated
Pool Operator(s)and attach a copy of the certificatice to tins form.
1. • fi/t, 2. ' 7 .
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community z
Cede Resuscitation(CPR),having one certified -s„•. • on at all times. Please list the � s w
employees below and attach copies oftheir to this The � wlr met use
past
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years records. You mint provide new copies and maintain a fie at your place brsmess. ;r C f ]
3. 2. �m ,
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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 awlication.The Health Department w*Rootuseposy sra'records. J. is
You must provide new copies and maintain a file at your establishment.
I. ti/il 2. Nil
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC_)on site during hours of operation,
I. 2. r r4
ALLERGEN CERTIFICATION&
All food service establiare required to have at least one fullfull-tuneemployeee who has Allergen certification,
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. You must
provide new copies and maintain a file at your establishment.
d. M/11- 2. N/42-
,
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-s s ,to trained in anti-choking procedures below and
You must
cop of employee certifications to this form. The ;=ft Department will not use past years'records.
provide new copies and maintain a file at your place of business.
L 2.
3. 4
RESTAURANT SEATING: TOTAL# /WY," 00l.--Nt4-0o- -0
ro
OFFICE USE ONLY
LI REQUIRED $55INN uPERMITS LI REQUIRED9(CABINGXPERMITS LICE REQUIRED FEE PERMrrit
CAMP ZLODGE i55 `SWIMMING MO(LSMOTEL ilage.
Sss ZCE2ZA PARK zees _WHIRLPOOL St lona
ROOD SERVICM
LICENSE REQUFEE PERMIT 4/ LICENSE IRED FEE PERMITS LICENSE FEE PERMITS
4100 SEATS 5125COtd�AL $as NON-PR�$30
>100 SEATS $200 COMMON VIC. $60
RETAIL SERVICE: =RKr�c rmN
LICENSE�gRIVUIRED FEE PERMITS LICEt�RES50 �QlUt.IRED PEE PERMITS LUCENSEREQUIRED FEE PERMITS
<50—*--;25,000 sq.it R. 3 �� DODaD ET$4O —_' ec VENDING-S i$0
NAME CHANCE: $15 AMOUNT DUE = S 66:06 oO
*****PLEASE TURN OVER AND COMPLETC OTHER UDE of FORM***
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town ofYannouth is now required to hold issuance ccrenewal
of any license or permit to operate a business if a person or company does not have a Certificate of Warl<ex'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 ATTACHE])
Town of Yarmouth taxes and liens must be paid prior t or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY:Forpu es of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to
the temporary and short tenn 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 ochry shaft
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 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 Dpartment to schedule the inspection three(3) 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 filingthe 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.varmouth.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 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 run annually from January Ito December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2019.
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 ' e ,II A SITE
DATE: /7 y SIGNATURE:
PRINT NAME& 11 ILE: -eifffi
Rev.innsnn
F
The Commonwealth of Massachiusetts
:::-..== Department of Industrial Accidents
_511 _ ' Office of Investigations
Ti
1 Congress Street,Suite 100
" Boston,MA 02114-2017
_�. = www nass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Anplicant Information Please Print Legibly
Business/Organization Name: ,.i : Aft. 5/ , Ea' `
Address: p'2$' f, s/ ,
City/State/Zip;$���/f`f lyte,�/ 40 63,7(,6 VPhone#: 5O 380.-/0
Are you an employer?Check the appropriate box: Business Type(required):
1.0 I am a employer with 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.)
ii ,loyees working for me in any capacity.
''o workers'comp.insurance required] 8. ❑Nam profit
3. Il. 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]*' 11.0 Health Care
4.0 We are a non-profit organization,staffed by volunteers,with no employees.[No workers'comp.insurance req.] 12.0 Other Gt, ` a'
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation. '.., ,.
**lithe 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:
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 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.
Ido hereby certir, ,7y he pains and pen •• of perjury that the information provided above is true and correct
T� r/�
Signature: / � ;1 4� , Date: ��/e
Phone#: 59 `4. "0 S YC
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 Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia