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HomeMy WebLinkAboutApplication and WC �*f" TOWN OF YARMOUTH BOARD OF HEALTH' ':t G3OVi= APPLICATION FOR LICENSE/PERIY T 1 ; ,! ,� i ��N 3 1 2020 .� /l * Please complete form and attach all necessary 3a v ' % ``a� 'i ecember 15 2017. Failure to do so will result in the return o. `pur P� ication packet. i4EAL.1 H DEPT, ESTABLISHMENT NAME: /5 / ' / P TAX ID: - ✓` LOCATION ADDRESS: / TEL.#: ( ?i 9- 404 MAILING ADDRESS: , /g ` - i ' l m -• bb5' E-MAIL ADDRESS: f,/ / / & QO,Ce OWNER NAME: CORPORATION NAME (IF APP CABLE : ', ern MANAGER'S NAME: TEL.#: "'%ll3t 3 35 MAILING ADDRESS: c-5 c l 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 p oyees currently certified in standard First A •: and Community Cardiopulmonary Resuscitation (CP' aving one certified employee on premises at - Imes. Please list the employees below and attach copi-. . their certifications to this form. The Healt 1 ! •partment will not use past yearsrecords. You must s -1 vide new copies and maintain a file at you i ace 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. 2. PERSON IN CHARGE: Each food establishment mu ave at least one Person In Charge (PIC) on site during hours of opera' 1. 2. ALLERGEN C''TIFICATIONS: All food service establishments are required to have at least one full-time employee , o has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 C ' 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will no use past years' records. You must provide new copies and maintain a file at your establishment. 1. 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 certifica 'ons to this form. The Health Department will not use past years' records. You must provide new copie nd maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# P,15---108-OS- OFFICE osOFFICE USE ONLY Oo P-ls--tiaq- 05-- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 =TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE 'E? IT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $.Ie- _>100 SEATS $200 COMMON VIC. $60 WHOLESALE r —RESID.KIT �.'• .80' RETAIL SERVICE: e QIC Q' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE b • D FEE PE I # T<25,000 sq.ft. $150 12.0,-Ol/ _FROZEN DESSERT$$40 OBA CO-FOOD$110 NAME CHANGE: $15 AMOT DUE = $ /6 ,On Z383 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****// ØÉ a41/r/= f( I/O /6 79 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 77 OR ,,� 7 WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior t newal 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. 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 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 CAFÉS: 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. 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, 2017. ALL RENOVATIONS TO ANY FOOD ESTABLISH - T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO ANfit AP ROVED B - BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY '. S P JAN. AP DATE: / ��/ SIGNATURE: V , PRINT NAME &TITLE: M /90: Rev. 10/12/17 • The Commonwealth of Massachusetts Department of Industrial Accidents =_7:1 t Office of Investigations -.-_-...,:e= 1 Congress Street, Suite 100 Boston, MA 02114-2017 -t ,1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly / ) Business/Organization Name: W , _ J S Address: 5i3 b i ' . .mass '2/*/ -\ 'q //11 r ��` 0,67-- Phone ��, City/State/Zip:W t<� A/ 0,67-- Phone #: (1.C4}G�92/1- ' �l� D Are you an employer?Check the appropriate box: Busi.en Type(required): 1.❑ I am a employer with employees(full and/ 5. etail or part-time).* 6. D 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. EI 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.❑ 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#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: - Insurer's Address: 1111111116111/.1 M, 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 . •. against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o* - .•IA for insurance coverage verification. - I do hereby ' , ,der th pai . an p nalties of perjury that the information provided a ove is ue and correct. V ,Signature: T Date: / �/ ,R0 Phone#: (00c3 , ?i32i 40b/ Official .e 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. 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