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Home My WebLink AboutApplication and WC " r TOWN OF YARMOUTH BOARD OF HEALTH _. DE@UWILD fi.. ,,i%) 'E APPLICATION FOR LICENSE/T .0 i --- /i 0'1M yr::'20 1 , U 9 2014 * Please complete form and attach all necessa , doc a .Ms y Decei ber 15, 2014. ur . � Failure to do so will result in the return of yoapplication packetHEALTH DEPT. ESTABLISHMENT NAME: ()/ ESt .i TAX ID. LOCATION ADDRESS: 4 TEL SS a MAILING ADDRESS: 4 rvyt o 11 t• I o r f l"Y\ ; ex-V19-fc--- E-MAIL ADDRESS: a/ 4 wa 14. A 11 e C a I s',11 n-42-1-- OWNER `'IOWNER NAME: 4,4 1a.- v i s cis.-4--et kik ez kiL_____,z. CORPORATION NAME IF A PL ALE : R' NAME: & c> 4 a TEL.#: 3(00).. s-s--a.a., MANAGE S 1� h MAILING ADDRESS: POOL CERTIFICATIONS: Theool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated p p 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 basic water safety, 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 past not use years' records. 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. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. r-f----ce,Se l/e f fcle Ca r 0 0 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 SanitaryCode for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certificationpp 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: Heimlich All food service establishments with 25 seats or more must have at least one employee trained in the all times. Please listyour employees trained in anti-choking procedures below and Maneuver on the premises at records. attach copies of employee certifications to this form. The Health Department will not use past years' p You must provide new copies and maintain a file at your place of business. 1 . A . i � +n • t t • ♦ 2. 3. 4. so RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: IRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED —INN LODGE $55 CABIN $55 _MOTEL $110 NN $55$55 CAMP $55 ___ SWIMMING POOL $110ea. NN TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE P � � CONTINENTAL $35 NON-PROFIT $30 / 0-100 SEATS $125 j `3 COMMON VIC. $60 /�– �-- WHOLESALE $80 >100 SEATS $200 d RESID. KITCHEN $80 RETAIL SERVICE: FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT LICENSE REQUIRED >25,000 sq.ft. $285 VENDING FOOD $25 __..<25,0000 sq.ft. $150 <50 sq $50 FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ � ;qCMO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** The Commonwealth of Massachusetts Department of Industrial Accidents Is ==z =- 01,7 Office of Investigations Lc:• ff g r =:x ,11 1 Congress Street, Suite 100 • 11=141 eli �yH 769 Boston, MA 02114-2017 %-7/7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: iivA-H-7) /2-Es Th-C1 '- Address: /57 lO u-ne 4 City/State/Zip: �,2;r IV A- (24,7 5 Phone #: 7) 8 2 a-�—..se -i---&-.=)_ Are yo an employer? Check the appropriate box: Business Type (required): 1 . I am a employer with Q employees (full and/ 5. E] Retail _.__ � or part-time).* i (a 6. Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, etc.) employees working for me in any capacity. workers' com . insurance required] 8• ❑ Non-profit [No p 3. ❑ We are a corporation and its officers have exercised 9. 0 Entertainment . their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11 .0 HealthCare 4. E] 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 #1. I am an employer that is providin workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 4. f- r Insurer's Address: City/State/Zip: Policy # or Self-ins. Lic. # t5 3 � Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy numb a 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 certify, under the pains and penalties of perjury that the information provided above is true and correct. Si_ ature: ,,,I,, . / ,J,', ,, _ Date: oZ r / Phone #: (50 •g‘ o� ta"-D- 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 ADMINISTRATION s s t Under q 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 v Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES V 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 wvwv.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, 2014. 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 COMME CEMENT. RENOVATIONS MAY REQUIRE A SITE PLA ___-. DATE: ' SIGNATURE: dedi PRINT NAME & TITLE: Rev. 11/03/14