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Home My WebLink AboutApplication and WC L`I--� W�±SI`�11� i.Rh�v a- ku, 7"----\,,, TOWN OF YARMOUTH BOARD 0 4 r"III . -„ r Q ILc''' APPLICATION FOR LICENSE/PE'Y$ 2,U j AN d 2 20a O r * Please complete form and attach all necessary # - men&. .y DeceJber.13,\201 ,. Failure to do so will result in the return of your application packet. -- NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER ISS. • B t.g'N ESTABLISHMENT NAME: 14 rt 9 lays}c -I <f HofI o r pia r q TAX ID: LOCATION ADDRESS: S 761 Ro T ck.w 110od wesi ci�/M,ait4 Ft4 626z3TEL.#: -99O-Z�20C➢ MAILING ADDRESS: S-7q duck icjn.�d pIVA/� L412 41(wir.4h1 HA M67 3 E-MAIL ADDRESS: . v'\a -c er zci vim) oncipl wcoc4 ( ,c,61-1 OWNER NAME: VD toad 3 CORPORATION NAME(IF APPLICABLE): lc w0Cc x riaAr .v Ple1(Q ALF 1 t..1-C. MANAGER'S NAME: ''Rtic.,if\•el OfeekAe i a TEL.#: 5-0K---int)-6.)in MAILING ADDRESS: S79 eudc-i-. to► Pnnr.k roles-{-ken iwvv-i-lr. W4 C.,'-7 3 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 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. 2. ....—,^_ 3. 4 . J • 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 defmed 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. ;;•-j- PtharY'_1 C b 2. Ye.t:-ti1 S1/1,0C PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. •--& e I 2. Kt Sinvc K. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defmed in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(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. . p1Qat aA'\ 2. 1 10ls.C l \�v\- .V' . G� • HEIMLICH CERTIFICATIONS: • `J 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. 'QoNice -r kithei 2 Tb 3. Ksn's-fo, 1, i-1"ro poSfinS 4. 2 nbe14. TarAsor1 RESTAURANT SEATING: TOTAL# Gtr, it aQ LODGING: OFFICE USE ONLY dd14, .-2A3ti LICENSE110 REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# CABIN _MOTEL $55 =LODGE CAMP -- 7:SWIMMING SWIMMING POOL$110ea $55 =TRAILER PARK $105$ ' _WHIRLPOOL $110ea FOOD SERVICE: L CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _I 0-100 SEATS $125 OC&-C-,(:)e7 _CONTINENTAL $35 >I00 SEATS $20pNON-PROFIT $30 COMMON VIC. $60 W 00-CZ —WHOLESALE $80 RETAIL SERVICE: RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE ' PERMIT# _<50 sqq.ft. >25,000 sq.ft. $285 <25,000 sq.ft. $1505FROZEN DESSERT $40 —TOBACCO -FOOD 1$25 10 • TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = S_ 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 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. 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 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: h/i 3 lfl SIGNATURE: Clopyytikid PRINT NAME&TITLE: �k��v`2 / raffli{. Rev. 10/15/19 I i i The Commonwealth of Massachusetts Department of Industrial Accidents =,4i= l Office of Investigations =41 ; 600 Washington Street _'4 114,= 9 Boston,MA 02111 t� , www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information • Please Print Legibly Business/Organization Name: Maplewood at Mayflower Place Address: 579 Buck Island Road City/State/Zip: W Yarmouth, MA 02673 Phone#: 508-790-0200 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with- J/ employees(full and/ 5. 0 Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no ? Office and/or Sales(incl.real estate,auto,etc.) 9. 0 Entertainment 10.0 Manufacturing 11. employees working for me in any capacity. 8Non-profit [No workers'comp.insurance required] 3.❑ We are a corporation and its officers have exercised their right of exemption per c. 152,§I(4),and we have no employees.[No workers'comp.insurance required]* ®Health Care 4.0 We are a non-profit organization,staffed by volunteers, 12.0 Other with no employees.[No workers'comp.insurance req.] *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#1. • I am an employer Mal is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: The Memic Group . Insurer's Address: 180 Glastonbury Blvd#304 City/State/Zip: Glastonbury. CT 06033 • Policy#or'Self--ins.Lic.# 3102804908 Expiration Date: 6/1/2020 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as re' ed and r 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 ye-r impr onment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day again e riolat.r. Be advisedthat a copy of this statement may be forwarded to the Office of Investigations of the DIA il Ae anc coverage verification. . I do hereby certify,under i nd penalties of perjury that the information provided above is true and correct. Signature: . s . Date: - O .. .: t... .. Phone tl: / ' ' 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.govldia