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Home My WebLink AboutApplication and WCI � W«1DSolL ' � TOWN OF YARMOUTH BOARD OF I�,�.'�� `'�S° �� APPLICATION FOR LICENSE/PERMI�� +�5�. t � ° ` „ ��y�O��D " * Please complete form and attach a11 necessary doc�tlent ` '" ecemb •l5 2014. Failare to do so will result in the return of your application pac t. 4 2014 ESTABLISHMENT NAME: lv��ve a�.c� S�r/��Ny�' TAX D• LOCATIONADDRESS: �4S✓ �y" �n"`'t- TEL.#: ' MAILING ADDRESS: � Y�� 1.�-� o1G i�f E-MAIL ADDRESS: .PCtn,✓ii� 8�i S/• �� OWNERNAME: � CORPORATION NAME (IF APPLICABLE): ,�ctitS��Yu /J�s�1��.ra�-e 1`S�"��-- MANAGER'SNAME: �a��'�-`id` �o�+A�DCE2VIN TEL.#:_�rl� 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. — --- . L , . . 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 not use past years' records. You must provide new copies and maintain a Tle 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.��riNL�frt.✓/e�yjPonry.l�S��.*�"y` 2. /CA�i°` f�eir� �TUhi✓S'u"''„'� PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �./ �Pe.v�sti _, _ �1�eo"�,� �'z^""2x- - - 2. �h'`.s�-�.+"'-r,�� !�vir � �zH ---�-� . ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fixll-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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. / /9�-�' 1. f`-�'_ � 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 a11 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 t►le at your place of business 1. G'�e /�N^� ��5� /lc/ �UN�ve 2. s�� 3. 4. RE$TAURANT SEATING: TOTAL# TO D — --- -- _ _-- ---0FFIE�US�-BPI�_. -- - LODGING: - -----_. _ . . .—___ _. LICENSE REQUIRED FEE PERMIT tt LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 � I1ViV $55 CAMP $55 SWIMMINGPOOL$110ea. _LODGE $55 _TRAILER PARK $l05 WHIRLPOOL $110ea. �'�, FOOD SERVICE: L[CENSE REQUIRED FEE PERMIT# [,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# 0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 � —RES[D.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,OOOsq.ft. $150 _FROZENDESSERT $40 TOBACCO $ll0 � NAME CHANGE: $15 AMOUNT DUE _ $ 30.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"' ADMINISTRATION ' ' Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yannouth is now required to hold issuance or renewal ' a�ariy ficense or permit to operate a business if a person or company does not have a Certificate of Worker's C4mpensation Insuranee. THE AT`I'ACHED STATE WO1tKER'S COMPENSATI0IY INSUI2ANCE AFFIDAVIT MUST SE COMPLETLD AND SIGNETI, OR CL;R"F'. OF INSURANCB ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens rnust be paid prior to renewal ar issuance of your pertnits. PLEASE CHECK APP120PRIATEI,Y IF PAID: YES Nt3 MOTELS AND OTHER LODGING ESTA.BLISHMENTS `TRANSTENT QCCUPANCY: For purposes ofthe limitations ofMoCel or Hotel use,Transient occupancy shall bc — limited to the temporary and short term accupancy,ordinarily and customarily associated with matel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence , elsewhere.Transient occupancy sha11 generally refer to contittuous occupancy of not more than thirty(30)days,and i 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 ar 830 CMR 54G, as amended, shall generally be considered Transient. PQOLS POOL OPENIAtG:All swimming,wading and whirlpaols which have been clased for the season must be inspected by the Health Department prior to opening. Contact the Healih Departrnent to schedule the inspection three(3) days priar to opening. PLEASE NOTE: People ara NOT allowed to sit in the pool area until the poal has been inspeeted and opened. POOL WA1'FR TE3TING: The water must ba tesked for pseudomonas,total coli£orm and standard plate eount by a State certified lab, and submitted to the Health Deparhment three (3) days prior to opening, and quarterly thereafter. P40L CLOSING: Every outdaar in ground swimming pool musf be drained ar 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 Heaith Department to schedule the inspectian three{3)days prior to apening. CATERIi�G POLICY: Anyane who caters within the Town of Yazmouth must notify the Yarmouth Health Department by fiIing the required Temparary Food Service Applicatian form 72 haurs prior to the catered event. These fqrms can be obtained at the Health Department,or from the Town's website at vwvw.�armouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frazen desserts mast be tested by a State certified lab prior to opaning and monthly thereafter,with sasnple results submitted to the Health Department. FaiIure to do so wall result in the suspension or revocation of your Frozen l7essert Permit untii the above terms have been met t7UTSIDE CAFES: (7utside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. CIUTDOOR COOI{ING: Outdoor 000king,preparation,or display of any food product by a retail or food service establishment is prohibited. ; NOTICE:Pernuts run annually from January i to December 31. IT'IS YOUR TtESPONSIBILITY TO RET`t.TRN , THE COMPI,ETEI}RENEWAL APPI,ICATION(S}AIVD REQLTIRED FEE(S}BY DBCEMBER 15, 2414. ALL RENOVATIONS TO A,NY FOdD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � F.,QUIPMEN`I', ETC.}, MUST BE REPORTEI}'1`C}�ND APPROVED BY THE BQARD C}F HEALTH PRIOR TQ COMMBNCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DA1'E: !a 1�1 SIGNATURE: ��`G�—">�---^ PRINT NAME&TI1'LE: /t tt1QT�t��Q/711D{ �"G�Ytt rAt5��e1t�+� , Rev. I tJ43J74 � ` � � The Commonwealth of Massachusetls ' Department of Industrial Accidents O�ce oflnvestigations ' I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dda Workers' Compensation Insurance Affidavit: General Businesses Apulicant Information Please Print Lesiblv Business/Organization Name: ��''�'�� Address: `��O � /`�. /i'l�'/�✓ s%/�.� City/State/Zip: s ?�/9n��u�, m�- Phone#: Sa�' 3`� `f'�3 S/Y Are you an employer? Check the appropriate box: Business Type(required): I 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBaz/Eating Establishment — ----- - 2. I am a sole ro rietor or armershi an�Fiave no P P P P 7. ❑ Office and/or Sales(incl.real estate, auto, etc.) , employees working for me in any capacity. [No workers' comp. insurance required] $� ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant thaz checks box#1 must also fill out the section below showing their workets'compensation policy informakion. ••If the corpornte office:s have exempted themselves,bu[the corporation has other employees,a workers'compensation policy is requued and such an organization should check box#1. . I am an employer that isproviding workers'compensation insurance for my employees. Be[ow is thepolicy injormation. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposi6on of criminal penalties of a — fine up fo$T,SOII:OO andto�o�e-yeaz imprisonrnen�as wet}as tivii penakies inth�fo..:-�,�s.cT�E}F WO�I4 0�9Ei�axi�a fin�- — , of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigations 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. Sienature: � �� Date: � L��'�I/ � Phone#: � D c��/ '� 3'S�/ � Ojficial use only. Do not write in this area,ta be completed by city or town officiaL City or Town: Permit/License# � Issuing Authority(circle one): ' 1.Board of Health 2.Building Department 3.CityfPown Clerk 4. Licensing Board 5. Selectmen's Office j 6.Other ' Contact Person: Phone#: www.mass.gov/dia � , ; �C�je �Cum»tottl�eatt�j �of ,�Ia�s'ac�jugettg L,icenseNo. , ; �a2 ' Serial No. 11$22 DEPARTMEN7 OF INDUSTRIALACCtDEN7S , � � , � , , � i ' � �vP�y I I } r�'` � �'�jt$' ��' LV KLQ�'ti'�p t��t BERKSHIRE HEALTHCARE 5YSTEMS,INC. AND ITS' 5UBSTDIARIES � � � af 75 Nor.�h �rr�flr� SrP_ ��n, p;rr�f;P1 .[+j�_{L�.�� , havirtgconformedxiththepravisionsof � saab puragraph ( 2, b ) af Sectian 2SA of Chapter 152 of the General Laws is herebv licensecl � � tvbeu „ � , SELF-IN��.TF�ER ; F S R S T , T3ris license zs effectri�e far n period of one yecrr fi�ans tbe day of � N 0 V E M B E R 2Q 14 at 12:Q1,4.M., unless soaner revoked. t � � PA 7MEN70FiNDU�=L NTS - i � ��- ' D I R E C T 0 R � TH�S LIGENSE MUST 9E POSTEDATTHE LQCATiON OF THE BUSINESS t ; �