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Home My WebLink AboutApplication and WC . . B_R_LS�DG� � � TOWN OF YARMOUTH BOARD OF H�ALTH '��, � � � APPLICATION FOR LICENSE/PERMIT -ch��J21� �`hN`� _ �/ ZQ14 "'°' * Please complete form and attach all necessary documents by Dece� r 1 Failure to do so will result in the return of your application pac ��'T ESTABLISHMENT NAME: TAX ID: LOCATION ADDRESS: ✓� � � TEL.#: MAILING ADDRESS: E-MAIL ADDRESS: � � OWNER NAME: � � � c � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ��f+� �„�� TEL.#: s r L� MAILING ADDRESS: S�d�� 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 certi.fication to this form. 1. N/� 2� Pool operators must list a minimum of two employees currently certified in basic water safety, standaxd 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 file at your place of business. 1.— /V�/� 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. Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. /'��L� Z. .-T 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. ��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-chokmg 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# 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 SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LIC�NSE 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: $is AMOUNT DUE _ $ S��OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** nnn�rris�rxaTiaN Under Chapter 152, Section 25C, Subsection 6,the Tpwn of Yarmouth is naw required to hald issuance or renewal of any iicense or permit to operate a Musiness if a person or company daes not have a Certificate of Worker's Compensation Insurance. TFIE ATTACAED 3TA1'E WOFtKI;R'S COMI'ENSATION INSIIRANCE AFFIDAVII" MUST BE COMPLETF;D AND SIGNED, OR C�RT. OF INS(IRANCE ATTACHED OR WORKER'S COMP. AFFTDAVIT SIGNED AND ATTACHI:D t/"" Town of Yazmouth taates and liens must be paid priox to renewal or issuance of youar perxnits. FLEASE CHECK APPROPRIATELY IF PAID: / XES t,/ NO MOTELS ANA I�THER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCX: For purposes ofthe limitations of Motel or Hote1 use,Transient occupancy shall be limited to the temparary and short term occupancy,otdinariIy and customarily associated with motel and hotel use. "1'ransiant accupants must have and be able to demanstrate that they maintain a principal place of residance elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirry(30)days,and an aggregate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a res'rdence or dwelling unit shall not be considered transient. Occupancy that 3s subject ta the collectian af Raam Oceupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS PQOL OPENING:All swimming,wading and whirlpools which have been closed for the seasan must be inspected by the Health Department prior to opening. ConYact the Health Department to schedule the inspection three(3) days prior ta opening. PLEASE NQTE: People are I30T a2lowed to sit in the pool area until the poal has been inspected and apened. POOL WATER TESTING: The water must be tested for pseudamonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3} days ptior to opening, and quarterly tihereafter. POC3L CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven{7}days af closing. - FOOD SF.RVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Departmeni prior to opening. Please contact the Iiealth DeparCment to schedule the inspection three{3) days prior to opening. CATEItiNG POLICY: Anyone who caters within the Town of Yatmouth must notify the Yarmouth Health Departrnent by filing the required Temparary Faad Service Application farm 72 hours priar ta the catered event. These forms can be abtained at the Health Deparhnent,or from the Tawn's website at www.yarrnouth.ma.us under Health Deparhnent, Downlaadabte Forms. FROZEN DESSF.RTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Deparhnent, Faiture to do sp will result in the suspension or revocation of your Frazen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. — __ ..____— ___ _ _ _ __._ — _ _ __— _ -_ _ .—_ OUTAOOR COOHING: Outdaor eooking,�arepazation,ox display of any food product by a retail pr food service establishment is prohibited. NOTICE;Permits run annually from January I to Deaember 31. IT IS YOUR IZESPONSIBILITY TO RETCTEZN THE COMPLETED RENEWAL APPLICATIQN(S}AND REQUIRED FEE{S}BY I}ECEMBER 15, 2014. ALL RENdVATIQNS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.}, MUST BE REPORTED TO�ND APPIZC?VED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ SITF, P N. DATE: ,��19'—lui SIGNATURE: �� PRiNT NAME& TITLE: � ,f � Rev.il(43f74 R � The Commonwealth of Massachusetts . _ _ Department of Industrial Accidents � - Office of Investigations ° 1 Congress Street, Suite l00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Legibly Business/Organization Name: �¢S"S' �i�i/ I� lf�.cx U� Address:�2��/Js,��i�/ S% S�v%f�T� G��/ ��/' � Da�� / City/State/Zip: Phone#: ��—�9��'—�� Are you an employer? Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5• ❑Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. workers' comp.insurance required] g• ❑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 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ He th Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12- ther *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 ezpiration 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�and the pai nd pe lties of perjury that the information provided above is true and correct. i Si ature: � Date: - - Phone#: SO - Official use on[y. Do not write in this area,to be completed by city or town officiaL City or Town• PermitlLicense# Issuing Authority(circle one): 1.Soard 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