HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH ` _`` `/
r.,
r , . ' APPLICATION FOR LICENSE/PERMIT-2020' N 0 V 0 8
*Please complete form and attach all necessary documents by pecetuber 13. O19. 20 9
Failure to do so will result in the return of your application packet.
NOM ALL BUSINESSES WITH LIOLIO.R LICENSES MUST R TURNFORMS 137 NOVEMBER,,5th. HEALTH DEPT.
ESTABLISHMENT NAME:candy Co. TAX ID:_
LOCATION ADDRESS: 975 Route 28,South Yarmouth,MA.02664 TEL 508-398-0000
MAILING ADDRESS- P.O.Box 126,South Yarmouth,MA.02664
E-MAIL ADDRESS: sweetesnolks@candycocapecod.com
OWNER NAME: Shaun MacKenzie
CORPORATION NAME(IF APPLICABLE): Cape Cod Candy Company,Inc 4'
4
MANAGER'S NAME: Shaun MacKenzie
TEL.#: 0,508-398-0000 y
MAILING ADDRESS: PO BOX 126,South Yarmouth,MA.02664
.... *'+.
POOL CERTIFICATIONS: n
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 farm.
N/A ':-.0
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. N/A
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.
N/A
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
N/A
1. 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(G X3)(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. N/A
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. N/A
3. 4...
RESTAURANT SEATING: TOTAL It ,k,ci—Z r?'l"%t
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRE!) FEE PERMITS LICENSE REQUIRED FEE PERMIT
B&B $55 CABIN $55 _
—INN $55 CAMP $53 —SWIMMING POOL$1 Inea.
-LODGE $55TRAILER PARK $145 wHIRI,POOL $tinea..
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REWIRED FEE PERMITS LICENSE REQUIRE!) FEE PERMIT
0-100 SEATS $125 _CONTINEQNTAL $35 NON-PROFIT $30
,_>100SEA TS $200
m: ___COMMON Vlt_`._ $6I1 WHOLESALE $110
RETAIL SERVICE: —RESID.KrreneN $80
LICENSE REQUIRED FEE PERMIT$ LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT It
<50 ssqqR. $50 >25.000 sq.11, $255 VENDING-FOOD$25
T<25,000 sq.!! $130 '-a.je° ..:V FROZEN DESSERT$40 ---‘TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE = $ /56.'
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORMVM**•**
ADMINISTRATION
Under Chapter 152,Section 2$C,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 x
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits, PLEASE CHECK
APPROPRIATELY IF PAID:
YES x 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.v.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 inspcted by the
Health s t prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to
opening. ..E`a I_ _ •Jr:People are NOT allowed to sit in the area until the pool has been inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total eoliform 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:
Mi 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 od
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be a at the
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 labprior 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(Le.,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 l to 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 REQUIRE A SITE PLAN.
DATE: 11/7/2019 SIGNATURE, ' c
PRINT NAME&TITLE: Shaun MacKenzie-Owner
Rev;10/15719
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
• """"" 7 / Office of Investigations
17411.71 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Cape Cod Candy Company, Inc. dba Candy Co.
Address: 973 Route 28
City/State/Zip: South Yarmouth, MA. 02664 Phone#: 508-398-0000
Are you an employer?Check the appropriate box: Business Type(required):
1.❑✓ I am a employer with 5 employees(full and/ 5. ✓❑Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and 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.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp.insurance required]** 11.0 Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 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 41.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Markel Insurance Company
Insurer's Address: Ten Parkway North
City/State/Zip: Deerfield, IL. 60015
Policy#or Self-ins.Lic.# MWC0148693-01 Expiration Date: 5/1/2020
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 certfTh t.
under the pains and penal '' of that the information provided above is true and correct.
Signature: -----7Z::_ ' Date: 11/7/2019
Phone#: 917-699-9760
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