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Home My WebLink AboutApplication and WC P � �� at�C��[D � � � TOWN OF YARMOUTH BOARD C1� A�'H;��-� � ---'; �, �� ,. = APPLICATION FOR LICENSElPE�� =, �� ` 3 � 1 t�l4 '""' * Please complete farm and attach all necessary t�oeum' ts�y�e�em er Failure to do so will result in the return of your application pa ��pT ESTABLISHMENT NAME: �a �'' T X D� LOCATION ADI?RESS: ( t�n �rz S' r�� TEz.#: r� -�l�' �u,rN� a��xEss: �n E-MAILADDRESS: l ffl�t. Yr l Y 1�?� OWNER NAME; C4RPORATIfJN NAME (IF APPLICABLE): ! j'�� " - MANACxER'S NAME: Y�`"I�S' �'i TEL.#: G��l�' I��AILING ADDRESS: � �i'�'17�- .�._. POQL CERTIFICATIQNS: The pool supervisar must be certified as a Pool Operator,as required by State law. Please list the designated Pool4per or(s) and attach a capy of the certificatian to this farm. 1. � � 2• Pool operators must list a minimum of twa employees currently certified in basic water safety, stanclard First Aid and Community Cardiapulmonary Resuscitation (CPR}, having one certified emplayee on premises at all times. Please list the ernployees belaw 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 pIace af business. l. —� ' � 2' 3. 4• ��__ ,_ FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-tirne employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 59Q.000. Please attach capies of certification to this application. The Health Department will nat use past years'records. You must provide new ca ies and maintain a �le at your establishment. s �. �. . . ..._..._...._—._ ._...-:_.._._._�- ._ ..._._ _ __..._.-.--.__z .___��."—.._.._.'__.,._ ___'_.._..___ . _ __i��i 'ii�'.�_._�,'�1=��`:_`__ __._ Each food establishment must have at least ane Person In Charge (PIC}on site during haurs af aperation. f M1 1. 2. ALL GEN CERTIFICATIONS: . All food service establishments are required to have at least one full-time employee who has Allergen certif cation, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR S9Q.009(G)(3)(a). Please attach copies of certification to this applicatian. The Health Department will not use past years' records, You must provide new copies.and maintain a �le at your establishment. i• �� 2. HEI CH CERTIFICATIONS: All foad service establishments with 25 seats or more znust have at 2east one empioyee trained in the Heimiich ; Maneuver on the premises at all times, Please list yaur employees trained in anti-choking procedures below and attach copies of employee certifications ta this form. The Health Department will not use past years' records. � Yau must provide new copies and maintain a file at your place of business. ; � � I3. - ` 4. RESTAURANT SEATING: TOTAL# LOD�iNc: QFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# B&B CABIN =�� 5 �S� - MOTEL $110 LODGB '��P _SWIMMING POOL$114ea, `TRAILER PARK $$05 _WHIRLPOOL $1 l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PBRMIT# LICBNSE REQ[JIRED FEE PERMIT# LICENSE IZEQLTIRED FEE PERMIT# Q-144 SEATS $125 .._CONTINENTAL $35 �NON-PRQFIT $3Q _>]00 SEATS $2Q0 �COMMON VIC. $60 WHOLESALE $8p RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LtCENSE REQUIRED FEE PERMIT# <54 sq.ft. $SO >25,000 sq.ft. $285 ;,<25,000 sq.8. $150 �FTtC?ZEN DBSSERT $40 VBNI?ING-FpOD $2S yTOBACCO $110 NAME CHANGE: �rs AMOUNT DUE _ ��o.00 *****PLEASE TURN OVER AND CpMPLETE OTHER SIDE OF FORM***** ` � _... __ _ t i ' . >,, , . . ADMINISTRATION �Y�. a Under Chapter 152, Sectian 25C,Subsection 6,the Town ofYarmouth is naw required ta hold issuance or renewal ` af any license ar permit to operate a business if a person or company does not have a Certifieate of VVarker's ' Campensatian Insurance. THE ATTACHED STATE WOItKER'S COMPENSATI4N INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ; f I CERT. OF INSURANCE ATTACHED ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Tawn of Yarmouth taxes and liens must be paid pri to renewal or issuance af your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES NO ; � ; � MOTEI.S AND OTHER LODGING ESTABLISHMENTS ` TRANSIENT t�CCUPANCY: Far purposes af the limitations af Motel ar Hatel use,Transient occupancy shall be limited to the temporary and short term accupancy,ardinarily and customarily associated with motel and hotel use. � Transient occupants must have and be able to demanstrate that they maintain a principai place of residence ,f elsewhere.Transient accupancy shall generally refer to cantinuous occupancy ofnot more than thirty{30)days,and an aggregate of not more than ninety(9Q)days within any six{6)month period. Use of a guest unit as a residence or dwelling unit shall not he cansidered transient. C?ccupancy that is subject to the callection of Raom Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be cansidered Transient. PfJOLS P40L OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department priar to opening. Contact the Health Department ta schedule the inspection three(3) f days priar to apening. PLEASE NOTE: People are NOT allawed to sit in the pool area until the pool has been inspected and opened. Pt30L WATER TESTING: The water must be tested for pseudomonas,tatal caliform and standard plate count ' by a State certified lab, and submitted ta the Health Department three (3} days prior ta opening, and quarterly thereafter. I�t��L t;°I.{QSI�T�: Every ou�daor in ground sv�irnsning pool rnust be drained or covered within seven(71 days af ' closing. FQOD SERVICE SEASGlNAL FUOD SERVICE 4PENING: All food service establisl�ments 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 P4LICY: Anyone who caters within the Town of Yarmouth must natify the Yarmouth Health Department by filing the required Ternporary Food Service Application form 72 haurs prior to the catered event. These forms can be obtained at the Health Departrnent,or from the Town's website at www.yarmouth.ma.us under Heaith Department, DQwnloadable Farms. FRUZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sampie results submitted to the Heaith Department. Failure ta do so will result in the suspensian or revocation of yaur Frozen Dessert Permit until the above terms have been met. OUTSTDE CAFES: C►utside cafes(i.e.,outdoor seating with waiter/waitress service),must have priar approval from the Board of Health. _ _ __ __ _ _- __, __ __ _ _ _ _- - -- _______ _____._____ _ _ ___ ___ 4UTDOOR C04KING: ' Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � PIQTICE:Permits zti�n annually fram January 1 to December 31. IT IS Y4UR RESPONSIBILITY TO RET'UKN ` THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2014. c ALL RENOVATIONS TO ANY F40D ESTABLISHMENT, MOTEL OR POOL (i.e., PAII�TTING, NEW i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPRCI�ED BIT THE BOARD OF HEALTH PRTUR TO C4MMENCEMENT. REN4VATIQNS MA REQUIRE AiSITE PLAN. DATE: �`,�l'``� SIGNATURE: PRINT NAME &TITLE: '��'�� L"�r �� ' a � Rev. 11/03/14 �` Departtnent of IndustriaX Accidenis Dff ce vf 1'nvestigations � � Con�ress Street,Suite 1 DD � Sastvn,.�A 02XX4-2a17 www.mass gov/dia Workers' Compensation Insuarance Affc�avit: GeneraI Businesses Abolicant Infarmatia�x Please Print Legibiv BusinesslUrganizationName��t , �` �`r.'�inet�'•�i �..�.`t�lf�Cl�$ ��'"��a�, � �f � Address: �� G`�+�• � �c� � �3z.� City/StatelZip; t3�'�' +c\ �� O`''•t Q$ Phane#: {v�1 �� " ��$� Ar�e,�y,,o�'�an euxployer?Cfieck the aQproQriate bog: Business Type(required): i.t� 1 atn a employer wifih �.�C3 employees(f�ll and! S. .CI Retaii or part time).* _ _ 6. ❑Restaurant7BarlEating Establishment . 2.❑ I am a sole proprietar or partnsrship azid�ave no 7, �p andlor Sales(incl.reat esta#e,auw,etc.} employees working for me in ariy capacity. [No warkers'camp.insurance requixed] 8. on profit 3.❑ We are a carporafion and its of�icers have exercised 9. ❑Entertaiarunent their right of exemp�ion per c.152,§I(4�,and we have ia.(��g no employees.[No virorkers'comp.insvrance required]* 1 i.Q Health Care 4.[] We are a non-profit organir.ation,ska.ffed by vohrMeers, with na emplayees.[No workers'comp.insurance reec�.] 12.(�Qther '`�Y$PP�r.ant that cheeks box�1 must at�filI aut the section helow showing theic workers'campeasario4 palicy Infomdat%am. "*I€the corpoxate afficers have exempteci thcarsclves,but the r„o�poration tuas at�er employces,a warke.rs'�mpensation policy is raqui�d and such� organization shoetid c6eck ko�c#1. I am an emplayer that is provi�di�g workears' mpens`�afion ' +anc�(for m�+employees. Below�S tJie pot�cy infarmatwn. Insurance Company Name: 1...��Q�2�� ' !t1��2` —1•i/b U �O�M Insurer's Address: S • � • 4 � � � City/$tate/2ip: Y�'+C..�c''J`�.1.� , � .a 5 i"� ��?Z. "" �Q�� Palicy�# r Se2f-ins.Lic.# ��•2"'• "` 31Jr' " �3�� _i—O2�.Er.piration D *�; � �'�"' � �.l !t�e+el�a co of the warkers'cam nsation lic declaratian e showin the aii number and 'ratiQn date. PY F� P� Y I�g t � P �3' � ) Failure to secure co�verage as required under Sectian 2SA of MGL c.152 can Iead to the imposition af criminal p�atties of a fine up to�I,500.(}0 andlor one-year imprisonment,as weli as civil penalties in the form of a STdP WORK ORDIIt and a fine af up to$250.00 a day against the violator. Be advised that a copy of t�is.statement may be forwarded to the Uffics of IavestigaEioas of the DIA far insurance coverage verification. I do hereby rti ,ander the pains und penaXi�'es vf perjury that the inforraativn prm�ided above£s#rue and carrect. ; �• � . �r'� D�c�• it- Z�-E • �� ' / f ' Phoz�e#: V�ti� 2.� � " L"�1 �� . r Clfficial use only, Do not write in tJcis area,tv he completed by ciiy or lown o�cia� Cit�or Town.: Permitli.icense# Issaing Authorfty(circte flne): . I.$oarct of Health Z.Beailding Department 3,Cityl7�'awn Clerk 4.Licensing Board 5.Selectmea's 4t�ice 6.Uther . Coutact Pexsoni Phone#: www.mass.gov/dia