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Home My WebLink AboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH l APPLICATION FOR MCENSE/PERIIIIT-2022 `"- _ r documents by December 18, 2021 * Please complete form and attach all necessa y Failure to do so will result in the return of your application packet. is TAX ID: i�i'��LL�� SillEga TEL.* • ESTABLISHMENT NAME: � , � � � � TE LOCATION ADDRESS: \` ��- •� '� � ��'�� '- ^� MAILING ADDRESS: ; (11 to �� s E-MAIL ADDRESS: (+ 1 ''..' OWNER NAME: MAPABLE): �LT`i ''�• ` C L CORPORATION NAME (IFTEL.#: �,•. MANAGER'S NAME: �k ` - V�' AIR `'�'- .EL. ' MAILING ADDRESS: POOL CERTIFICATIONS: certified as a Pool Operator,as required by State law. Please list the designated The pool supervisor must be Pool Operator(s) and attach a co' of the certification to this form. 2. 1. a minimum of two employees currently certified in nstanamals times.Aidnd Co list the Pool operators must list havingone certified employeepremises employees ees below and Resuscitation (CPR), file at e ptce of attach copies of their ceifications to this form.The Health Department will not use pa years'mployeec below rovidfnew copies and maintain usiness. records. You must p 2. 1. 4. 3. are required I have at Nast one full-time employee who is certified as a Food FOOD PROTECTION MANAGERS GERS q ired to CATIONS: ce whots, 10CMR 590.000. Protectionl food service establishments as definedast years'records. Manager, as in the this State Sanitary The Health Department will not rise-past` Please attach copies of certification to PP ?Lid You must pr i vide new opi=_ and maintain a file at your establishment. He 7 ��L1 1 Imi 2. PERSON IN CHARG - g on site during hours of operation. Each food establishment st ha at least one Person In Charge (PIC) 2. 1. A ALLERGEN CERTIFICATIONS: to have at least one full-time employee who has CAll3er Allergen Please attach All food service establishments are required CMR theertification, State Sanitary Code for Food Service Establishments,ill not use pasOt�ears)records. You must as pefined in application. The Health Department copies of certification to this app • provide new copies and i a' in a file at your establishment. C I 1 1V ; A 2. 1.HEIMLICHLI service e CERTIFICATIONS: in anti-choking trained iprocedn the below and Maneuverh l d r on t eo have aestablishments at all times. Please list your employees trained attacht copies of employee certifications to this form. The Health D f ar businesswill not use past years' records. You must provide new copies and maintain a file at your place 2. 1. - 4. , 3. RESTAURANT SEATING: TOTAL# ______t42 ------- OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LODGING: MOTEL $1E LICENSEB &BREQUIRED FEE PERMIT# CABIN $55 -SWIMMING POOL$110ea.� _INN $55 _CAMP $55 —- SWIMM NG $110ea._� _INN $55 __TRAILER PARK $105 _LODGE- X55 ----- PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE FOOD SERVICE: NON-PROFIT $30 LI EN0E REQUIRED FEE PERMIT ONTINENTAL $35 — —WHOLROFIT $80 ---- 0-100 SEATS $125 --- OMMON VIC. $60 _RHOD.KITCHEN $80 _— >100 SEATS $200 _— LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT RETAIL SERVICE: VENDING-FOOD $25 LICENSE<50sREQUIRED FEE PERMIT# >25,000 sq.ft. $285 _VENDING $110$2 2s .ft. $50 =FROZEN DESSERT $40 \ � —<2s,o`�o sq.ft. $1 so AMOUNT DUE = I NAME CHANGE: $15 —� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 1 ADMINISTRATION Under Chapter 152,Section 2SC,Subsection6,\heTow�ofY MUM reglvreato�c1a or any license or permit ' to operate a business if a person or company does not have a CertificateCe or cone( Compensation Insurance. THE ATTACHED STATE WORKER'S AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR COMPENSATION INSURANi CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal APPROPRIATELY IF PAID: or issuance of your permits. PLEASE CHEC YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel the temporary and short term occupancy,ordinarily and customarily associated with must have and bable ho t t demonstrate that theyuse, tel a d ht occupancy shall hotel use. Transient t occupant:ti maintain a principal place of residence elsewhere. Transient occupancy shat generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate within any f o month period. of a occupancy steal. Occupancynsixt is6 subject to the Useion of Room unit as my Excise,coradef' of not more thanonninety ran days guest as a residence dwelling unit shall not be considered transient. amended, shall generally be considered Transient. men in M.G.L. c. 64G or 830 CMR 64G, as POOLS All swimming, OPENING: wading and whirlpools which have been closed for the season opening.Health Department LEASE NOTEo opens are Contact the Health Department to schedule must be inspected by the T allowed to sit in the pool area until the pool has been inspecton three ed and opened.s prior r to POOL WATER TESTING: The water must be tested for pseudomonas ied lab, and to the Health Department be es three(3) p total coliform and standard plate count by a State POOL CLOSING:Every days prior to opening, and quarterly thereafter. outdoor in ground swimming pool must be drained or covered within seven7 � )days of closing. FOOD SERVICE SEASONAL NIN All food serviceFOOD establishmentsSERVICE mustOPEbe inspected by the Health Department prior to o Please contact the Health Department to schedule the inspection three(3)days prior to opening. pening. CATERING POLICY: AnyonAnyone who caters within the Town of Yarmouth eawoFoodcateServicewitn the Toon fofm 7must to thethe catered event.auth Health Department uired Temporary or rom c Town's webtion iteform atm 2 w.houarmoutrs prion ma us under Health These forms an beo fable filing t s.the Health FROZEN DESSERTS: Department,Downloadable Forms. Frozen desserts must be tested by a State certified lab prior to opening ane Health Department. Failure to do so will result in the suspension odr nhly thereafter,with sample results submitted the terms have been met. revocation of your Frozen Dessert Pennibuntil the OUTSIDE CAFES: Outside cafes(i.e., outdoor seating b 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 wfio has failed to renew-hisor"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. i NOTICE:Permits run annually from January 1 to Dece THE COMPLETED RENEWAL APPLICATIONS mber 31. IT IS YOUR O AND REQUIRED FEE(RS)EBYO DECEMBER 1 ILITY O RETURN ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT M g, 2020. OTEL OR EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVEDPOOL (i.e., PAINTING, NEW BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE S U P E S DATE: / ITE PLAN. SIGNATURE: AAi PRINT NAME & TITLE: 1 C_ �,'f Rev. 10/15/19 III i:` �� • 1 D TOWN OF YARMOUTH BOARD OF HEALTH < APPLICATION FOR LICENSE/PERMIT -2021 * Please complete form and attach all necessary documents by December 18, 2020. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: TAX ID: LOCATION ADDRESS: TEL.#: MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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 yearsrecords. You must provide new copies and maintain a file at your place 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. -- _ _—_ PFRCONCHARGE'• Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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)(3)(a). Pleaseattach 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. 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT 4 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 SERA : LI NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ONTINENTAL $35 NON-PROFIT $30 >100 SEATS $2000MMON VIC. $60 _WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 1 S *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 18, 2020. 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: SIGNATURE: PRINT NAME & TITLE: Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-18-0021-04 Issue Date: 1/1/2022 Mailing Address: Location Address: BAGELS BEYOND CC, LLC 311 ROUTE 28 BAGELS &BEYOND WEST YARMOUTH,MA 02673 311 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2022 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 19 RESTRICTION: Disposable service only;no stove or fryolator;;no public toilets;hours of operation will be 6:30 a.m to 5:00 p.m. Board Hillard Boskey,M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston ci Bruce G. Murp y,MPH,R.S.,CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $185.00 Food Establishment License Number: BOHF-18-0021-03 Issue Date: 1/1/2021 Mailing Address: Location Address: BAGELS BEYOND CC, LLC 311 ROUTE 28 BAGELS & BEYOND WEST YARMOUTH, MA 02673 311 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2021 LICENSE TO OPERATE: Food Service; Common Victualler This license is granted in conformity with the statutes and ordinances relating thereto, and expires December 31, 2021 unless sooner suspended or revoked and is not transferable. Conditions SEATING: 19 RESTRICTION: Disposable service only; no stove or fryolator; no public toilets; hours of operation will be 6:30 a.m to 5:00 p.m. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, MPH, R.S., CHO Health Director The Commonwealth of Massachusetts --- Department of Industrial Accidents ' =yip. Office of Investigations -. ; ...., 1 Congress Street, Suite 100 -_';, Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly • / /J Business/Organization Name: 0. ' ;t , yi e(. �, t 43 6(r.'e I S ' ��nr}' (Lett be_ 4 • Address: A / � �Cit City/State/Zip: �:�GS � �,� �( �C ?3 Phone #: SL � / � � 00 Are ou an employer? Check the appropriate box: Business Type(required): I I am a employer with ] employees(full and/ 5. [1] Retail or part-time).* Er.—fig 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. ❑ 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 IG.❑ Manufacturing no employees. [No workers' comp. insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp. insurance req.] 12,❑ Other *Any applicant that checks box#I 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 that is providing workers'compensate j ins ran�cefo�r my employees. Below is the policy information. Insurance Company Name: .Y OI _ b /L vim r Insurer's Address: Ja` -4\o ' - NRse City/State/Zip: i \kovvyk. AAA 0 ah 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. I do hereby cert'y,u ider the,pains and penaltie S of per ry that the information provided above is true and correct. Signature: ( ,r/ _ Date: PI 3 Phone#: 5 0 % 1 q 0 .%S 1)0 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 ,Z„ NOTICE NOTICE I..rr•alt r TO ......�a 1,._. rig -,�„ � ■ _.. amm { EM PLOYEES ',66.4 = annirEMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA 02111 (617) 727-4900 —www.mass.gov/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: NORFOLK & DEDHAM MUTUAL FIRE INSURANCE COMPANY NAME OF INSURANCE COMPANY 222 AMES STREET, DEDHAM, MA 02026 ADDRESS OF INSURANCE COMPANY WE187314A 07/06/2021 POLICY NUMBER EFFECTIVE DATES PO BOX 1053 SANDWICH, MA 02563 THE INS. AGCY OF CAPE COD NAME OF INSURANCE AGENT ADDRESS PHONE# 311 ROUTE 28 508-364-4196 BAGELS BEYOND CC, LLC W YARMOUTH MA 02673 EMPLOYER ADDRESS 07/06/2021 EMPLOYER'S WORKERS'COMPENSATION OFFICER(IF ANY) DATE M ED ICAL TREATM ENT 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 Workers' 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 ser- vices 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 NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Form WC 88 20 01 C Printed in U.S.A. INSURED COPY