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HomeMy WebLinkAboutApp-License-Certifications a TOWN OF YARMOUTH BOARD OF HEALTH .E ►' '',CAPPLICATION FOR LICENSE/PERMIT-2022 * Please complete form and attach all necessary documents by December 18, 2021. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: [,!AltovY7�, /e--es6,i -i" TAX ID: - LOCATION ADDRESS: ,34/3 L--L k.-s- (,) .11 A-A42i TEL.#: .off? 7 ' S I s MAILING ADDRESS: E-MAIL ADDRESS: .1 i z11Z(�� 04-f4 7 'C'944 OWNER NAME: c7A.,c,A'4_44--.0 vii- ps e9 Al�o ac`'c°441,r S. CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: I414.ck Apt TEL.#: s'o.V 7.37 44 ley MAILING ADDRESS: Po sole Z1'' 17 ,.-r`2 74,A- 0 3-4& Y 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. ciac,ia t10-1*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 � n . i ' ;AO S j ✓c'—I 2. . .e iZe",t�j riwc '3. *,ku LiPe -kq 4. ]'7G6,e-e4 7 hirv.,s 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. ECEIVED 1. 2. APR 1 2 2022 PERSON IN CHARGE: HEALTH DEPT. 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). 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. 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 $55FEPERMIT# LICENSE QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B — $55 I 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 PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 _NON-PROFIT $30 _>l00 SEATS $200 —COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT 4 _<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 = $ ,�• O ' e6/av *****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. ?AA DATE: vl ( SIGNATURE: PRINT NAME &TITLE: \ 1 w Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License Number: BOHL-15-1728-06 Issue Date: 1/1/2022 Mailing Address: Location Address: YARMOUTH RESORT CONDOMINIUM TRUST 343 ROUTE 28 THE YARMOUTH RESORT WEST YARMOUTH. MA 02673 343 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Motel 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 *MOTEL ROOMS- 134; 1 MANAGER UNIT. (Revised 03/28/08) *RESTRICTION: No on-site laundry until the laundry septic system is repaired. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston411 A / Bruce G. Murphy, MPH, R.S C 0/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1729-06 Issue Date: 1/1/2022 Mailing Address: Location Address: YARMOUTH RESORT CONDOMINIUM TRUST 343 ROUTE 28 THE YARMOUTH RESORT WEST YARMOUTH. MA 02673 343 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE 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 INDOOR SWIMMING POOL Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston //,) e ruce . Murphy, MPH, R.S., I O/James G. Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1734-06 Issue Date: 1/1/2022 Mailing Address: Location Address: YARMOUTH RESORT CONDOMINIUM TRUST 343 ROUTE 28 THE YARMOUTH RESORT WEST YARMOUTH. MA 02673 343 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE 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 WHIRLPOOL/VAPOR BATH LICENSING Board Hillard Boskey, M.D.,Chairman Mary Craig,Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston 41 e Bruce G. Murphy,MPH,R.S.,C 0/James G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1730-06 Issue Date: 1/1/2022 Mailing Address: Location Address: YARMOUTH RESORT CONDOMINIUM TRUST 343 ROUTE 28 THE YARMOUTH RESORT WEST YARMOUTH. MA 02673 343 ROUTE 28 WEST YARMOUTH, MA 02673 IS HEREBY GRANTED A 2022 LICENSE 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 OUTDOOR SWIMMING POOL Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston 111 e r. Bruce G. Murphy, MPH, R.S.,C I / . .1 es G.Gardiner Health Director/Assistant Health Director The Commonwealth of Massachusetts Pilot Form i Department of Industrial Accidents i 1— It" Office of Investigations 1 Congress Street,Suite 100 t zu•— Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: "4-4-ti--,-0.-)7` Citi Itv 14:4-L( T� Address: City/State/Zip: ��� � -I _ Phone #: Scu'- 7�,f- S Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with 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. ❑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]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Care 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#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: 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 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/ under the9pains_ and penalties of perjury that the information provided above is true and correct. Signature: i Z '7 Date: A' / 27'x- Phone#: 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. 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The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining E R — — -- THIS DOCUMENT IS VOID IF REPRODUCED nSC ■•:nsc Security Control No. LEARNING 858851 LEARNING Yacha Watkis • has completed the We want your feedback! NSC First Aid,CPR&AED Course Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 0312212022 take a brief survey and share your opinions Expires: 03/2212024 InstructionalHours: about the NSC course you completed. t.i �?� #1040918 Instructor Signature Instructor No. ..._______._.... Keep this card f' a , d if reproduced. 100M03092021 543401®2020 National Safety Council 79178-0100 1i : nsc NSC Fir9Jd CPR .vww.ca : coa�eraini<>l� & AED Course Includes Adult/Child/Infant CPR/AED Choking, First Aid, Epi Pen Name:Catherine Watson Security Control No. Address:The Yarmouth Resort Address:343 Route 28 858241 City, State, zip:West Yarmouth, MA 02673 Course Completion Date: 03/22/2022 Training Center: Cape Cod Safety Training Expiration Date: 03/2212024 Instructor Name: Rick Todd Instructor Number: 1040918 Catherine Watson has successfully completed the NSC First Aid, CPR&AED Course. The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED nscnsC Security Control No. LEARNING LEARNING 858241 Catherine Watson has completed the NSC First Aid,CPR&AED Course We want your feedback! Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 03/22/2022 take a brief survey and share your opinions Expires: 03/22/2024 InstructionalHours: about the NSC course you completed. 4-14" � �r #1040918 Instructor Signature Instructor No. Keep this card for your records.Void if reproduced. 100M03092021 543401©2020 National Safety Council . • nsc NSC First Aid CPR LEARNING & AED Course Includes Adult/Child/Infant CPR/AED Choking, First Aid, Epi Pen Name:Deborah Robbins Security Control No. Address:The Yarmouth Resort 858242 Address:343 Route 28 City, State, Zip:West Yarmouth, MA 02673 Course Completion Date: 03/2212022 Training Center: Cape Cod Safety Training Expiration Date: 03/2212024 Instructor Name: Rick Todd Instructor Number: 1040918 Deborah Robbins has successfully completed the NSC First Aid, CPR&AED Course. The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining J THIS DOCUMENT IS VOID IF REPRODUCED : : nSC � ::nsc Security Control No. LEARNING858242 LEARNING eborah Robbins has completed the We want your feedback! NSC First Aid,CPR&AED Course Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Date: 0312212022 take a brief survey and share your opinions Expires: 03122/2024 InstructionalHours: about the NSC course you completed. AG - #1040918 . Instructor Signature instructor No. Keep this card for your records.Void if reproduced. 100M03092021 543401©2020 National Safaty rniinril .. Pro PR CONTINUING EDUCATION:EQUIVALENT TO 6.0 CLASSROOM HOURS ++++ N By ProTrainings SCAN THE QR CODE TO LEARN HOW TO APPLY FOR CONTINUING EDUCATION CREDfTS'.9.. Adult, Child and Infant, Pediatric CPR/AED Et0 ,tri CERTIFICATE NUMBER First Aid •• 0 164944418584690 `•; Patricia Tibbetts tiT , '• '' • L1 INSTRUCTOR DATE ISSUED RENEW BY %•� r 08 Apr 2022 08 Apr 2024 • • -• ROY W.SHAW 0100 THIS CARD CERTIFIES THAT THE INDIVIDUAL HAS SUCCESSFULLY COMPLETED THE NATIONAL COGNITIVE EVALUATION IN ACCORDANCE WITH PROTRAININGS scan code or enter certificate number at protrainings.com/validate CURRICULUM AND THE 2020 AMERICAN HEART ASSOCIATION®GUIDEUNES www.protrainings.com support@protralnings.com L -J Dear Patricia, Your ProFirstAid certificate is printed above. You can access this page anytime by logging into www.protrainings.com and clicking Print Certificate. Sincerely, The ProTrainings Team P.S. If you had a good experience with us, please tell others about ProTrainings!