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Home My WebLink AboutApplication and WC! RECEIVED .,,,......„ TOWN OF YARMOtifil BOARD OF HEALTH ,A....*„.„, N APPLICATION FOR LICENSE/PERMIT-2020 DEC 12 2019 i \ 1._i *Please complete form and attach allnecessary documents by December 13.201i. Vailure to do so will result in the retum of your ap,plicntiOn packet NOTE:ALL BUSINESSES WITItLfOUOR LICENSES AlUSTRETUE N FORMSitir NOPEMRFIE Is", HEALTH DEPT. ESTABLISHMENT NAME: I'f(U)S W 1 CACe trrAitrei\J TAX ID: LOCATION ADDRESS:ADDRESS: i 01,4e r-,014.--1-S Zge . jlt .fliNATIA TEL.*: 0ii- ..,. MAILING ADDRESS: " Illyt.V.') -ma-E-MAIL ADDRESS: 1A-U,c)1A/Aele..6'D‘Ct t-ctitr4e.:Givrt-i L. ...-OWNER NAME: Sfttlk-4.30k5.00 etp..ftrWa1tr_14 CORPORATION NAME(IF APPLICABLE): 4;me-ow or MANAGER'S NAME: ,Aso istgA-m.got t-i, ...--__ pi,._ . . _ .. --, TEL.*: (3%'-'4)i -1410 0 mmuNe ADDRESS: 945 ft4 b LE'V'r*-1 44 Aktiecit$tic M t Li--S 0210 4 t POOL CERTIFICATIONS: The pool supervisor must be certifies:1ns a Paai Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. I. 2. . dr 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 ;1 employees below and attach-comes of their certifications to this form,The Health Department will not use past yearsrecords. You must provide new copies and maintain a file at your place of business. C 1. 2, 6 3. 4, FOOD PROTECTIOW MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manageras defined in the State Sanitary Code for Food Service Establishments,105 CMR 590,000. Please attach copies ofeertification to this application. The Health Department will not use pastyears'records. You must provide new copies and maintain a the at your establishment. 1, 6 PC '1)'N Oktail\/\ eCtit—I 2SA-f-A 60Th g IPVCAA, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. i1)1\1 kuvNivkig Pft_ 9\1z-A 6iv,tiyirleer( €4 2. ALLERGEN CER1 LP(CATIONS All food service establishments are required to have at least one full-lime employee who has Allergen ccItification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR$90.009(GX3)(a). Please attach copies of certification to thisapplication. The Health Department will not We past years"records. You must provide new copies and maintain a file at your establishment. I,.. 3M-6\I InUM‘13;:r1W PiffM, sikv-il a ISr\-cLk.- 2. HEIA4LICH.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 rm. The 11.... Department will not use past years"records. You must provide new copies and maintain a at your place of business. I, (\ft.Dir\) b.'g-11-rviervvk i Sile-il 601vinelPit,(.4- 3. 4, RESTAURANT SEATING: TOTAL* 3% 601t ,. le-2,012-02- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT S B&B $55 CABIN $55 MOTEL $110 --Nisi $55 cAttitp $55 SWIMMING POOL SI I IIIAC 10DOE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: • LICENSE REQUIRED PEE PERMITS LICENSE REQupoo FEE PERMIT S I 100 Y._._ v 4". Nox-papar $10 - 4 1 COMMON v1C. $so -7430 VAICiLESALE $50 - —REED).arretina EVJ RETAIL SERVICE4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIIMD FEE PERMIT li <50 +.11. $50 >25,000 sitilt. 54I85 VENDIND-FOOD $25 ‹25. i 1 sq.ft. $150 _ =FROZEN DESSERT$40 TOBACCO 5110 --_-_ NAME CHANGE: $/5 AIVIOUNTT DUE .-- S 185,00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OR FORM***** 1 ADMINISTRATION Under Chapter 152,Section25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or-renewal of any license or permit to operate a business ifs person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORICER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OitNJ 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 oldie limitations ofivfotel or Hotel use,Transient oceupancy shall be limitedto 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 oceupahcy shall generally refer to continuous occupancy oftiot more than thirty(30)days,and all aggregate often-moos that Uin ,(9Q}days within any six(6)month peried. Use of a guest unit as a residence or dwelling unit shall not be moldered transient Occupancy that is subject to the onni.etfOO of Room Ocoupancy-focist,as defined hoht0.1„c.640 or 830 CMR 640,as amended,shall generally be considered Transient POOLS POOL OPENING;MI 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 inspectko three(3)days prior to opening-PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspectedand opened. POOL WATER TESTING; The water must be tested for poseudmnottas,total coliform and standard plate count by a State certified lab,and submitted to the Health 13epariment three(3)days prior to opening,and quarterly thereafter, POOLCLOSING: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 convict the Health Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who eaters within the Town of Yarmouth must notify die Yarmouth Health Department by fitthe requited Temporary Food Service Application form 72 hours prior to the catered event- These forms can be oh at the Health Department,or from the Tossn's website at www.yarmouthonnos urtder 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 T0110=0:1011 OfyOUT Frozen Dessert Permit until the above terms have been met OUTSIDE CAVES; Outside cafes(Leo outdoor seating with waitettwaihess serviete),Must have prior approval from the Board of Health, OUTDOOR CoOKH4G: Outdoor cooking,pneparad011,or display of any food product by a retail or food serviceestablishment 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 December31.IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED IEE(S)BY DECEMBER 13,2019.. ALL RENOVATIONS TO AW(FOOD ESTABLISHMENT, MOTEL OR POOL (1.e.,PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND 4'PROVED BY THE BOARD OF HEALTH PRIOR , TO CONSIE CEMENT. RENOVATIONS MAY RE$( 44,0 PLAN- , DATE: LI al SIGNATURE: F wit\i,11 PRINT NAME&TITLE: A r &WOWS/tali) Rvv,10155/59 WBND452744 3206088 iZts. • NOTICE NOTICE TO AMMO *iglarTO EMPLOYEES MAL= EMPLOYEES =1 MSM v; toy R vrr_AL.• The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017 617-727-4900 - http://Www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: CITIZENS INSURANCE COMPANY OF AMERICA NAME OF INSURANCE COMPANY 440 Lincoln Street, Worcester MA, 01653 ADDRESS OF INSURANCE COMPANY WBN-D452744-02 12/18/2019 POLICY NUMBER EFFECTIVE DATES ROGERSGRAY,INC. 434 ROUTE 134 800-553-1801 NAME OF INSURANCE AGENT ADDRESS PHONE YWK ENTERPRISES LLC 1076 ROUTE 28 EMPLOYER C I� - �SS is EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) I ATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and In the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the Insurer, If the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the �"� L �p (�j� OfrOei(Xo I` Ili 9-14)1W-t_ S �` eg l f 'Q�v " S NAME OF HOSPITAL ADDRESS J • TO BE POSTED BY EMPLOYER 700047