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Home My WebLink AboutApplication and WC � WoK-N-Rou � TOWN OF YARMOUTH BOARD OF HEALTH p� ��`� t;�Y : 0 [U14 �� APPLICATION FOR LICENSE/PERMTT -20151,, �� ,, Ur, * Please complete form and attach all necessary documents by Decemb r 1 DEPT. Failure to do so will result in the return of yotir application pac . ESTABLISHMENT NAME: ' k - � � T ID: -/ / LOCATIONADDRESS: �% cv� � - G�t/ryl0 ,TEL.#: � - �O-� � . MAILING ADDRESS: <4 � G� Dil�- E-MAIL ADDRESS: �� 401. CO✓v� . OWNERNAME: 1,��9nP Q - �-O CORPORATION NA E(I APPLICABLE): ,�4 ra n o Z� . MANAGER'S NAME: -S�u i'Yl u�I �o TEL.#: __�`,D S- ']60 -�d o. MAILING ADDRESS: �S�t3M� �9S -f�$oflZ- • 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. __ - -- - - - — �. --- - -- - _ 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 File at your place of business. 1. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 �le at your establishment. 1. �QwI�t,¢ I �h-o . 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. __1. . J�,fY1 La_L'.� �k1 �- __ _ �� _--_ 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 190n�J � . �Oc,� � 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ar 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 �le 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 $55 SWIMMING POOL$I l0ea LODGE $55 TRAILERPARK $105 _WHIRLPOOL $110ea FOOD SERVICE: � � LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED EEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 '/ �OSB CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 LCOMMON VIC. $60 _,_��t�.SO _WHOLESALE $80 — —RESID.KITCHEN $80 � . RETAIL SERVICE: L[CENSE 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: $I S AMOUNT DUE _ $ i cg cJ -O d •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �'� T ��6-� , f C,.P� Z`K5 i112.�/`i � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal a£any license or perxnit to operate a business if a person or cornpany does not have a Certificate of Worker's Compensation Insurance. TkIE ATTACHEA STATE WORKER'S COMPENSATI4IY INSURANCE AFFIAAVIT MiTST BE COMPLETED AND SIGNED, QR CLRT. QF INSURANCE ATTACHED OR WOR.KER'S COMP. AFFII7AVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal ar issuance of your pertnits. PLEA SE CHECK APPROPRIATELY IF PAID: YES_� NC? MOTELS ANA OTH�R LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the lunitations ofNlotel or Hote]use,Transient accupancy shFill be limited to the temporaty and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrata that they maintain rz principal place af zesidence elsewhere.Transient occupancy shall generally refer ta continuous occupancy of not more than thirty(30)days,and an ag�regate af not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shali not be cansidered transient. Occupancy that is subject to the collactian af Room Occupancy Excise,as d�fined in M.G.L. c. 64G or 83Q CMR 54G, as amended,shall generally be considered Transient. raar�s PQOL OPENING:All swimming,wading and whirlpools which have been clased for the seasom m�st be inspected by the Health Department prior to apening. Contact khe Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTL: People are NOT allowed to sit 3n the pooi area until the paol has been inspected and opened. POQL WATER TE5TING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Departinent three (3) days prior to opening, and quarterly thereafter. 1'OC1L CL4SING: Every ontdoor in ground swimming paoi must be drained or cavered within seven(7)days of alosing. FOOD SF.RVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must ba inspected by the I Ieatth Department prior to opening. Please cantact the liealth Department to schedule the inspection three(3) days prior to opening. CATERING 1'4LICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health llepartment by filing the requzred Tempa Faad Service Appticatian form 72 hours priar ta the caterad event. These farms caza be obtained at the H�h Departrnent,nr from the Town's website at www,yannouthma.us under Health Department, Downlaadable Forms. FROZEN DESSERTS: Prozen desserts must be tested by a State cerkified lab prior to apening and monthly thereaRer,with sample results submitted to the Health Department. Failure to do so will resuIt in the suspension or revocatian of your Frozen Dessert Pernut untii the above lerms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress sarvice),must have prior approval frorn the Board of Health. OUTDOOR COt7HING: Qutdoor cooking,prepazation,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 RES�'ONSIBILITY TO R�TURN THE COMPLETED RENEWAL APPLICATION(S}AN73 REQLTIRFI}FEE{S} BY DBCEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQLiIPMENT,ETC.},MUST BE REPORTED T{}AND APPRC}VED BY THE BOARD OF I-SEALTH PRIQR TO COMMENCEMENT. RENOVATIONS MAY REQ IRE A SITF, PLAN. r�A�"E: t � (6 ��{- SS�rrATUt�: ' PRINT NAME& TI1'LE: �YE7 p S .�c�� _ � Rev. iltp3114 ' '^ � � The Commonwealth ofMassachusetts Department of Industrial Accidenis Offace oflnvestigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: � � K - h - �0 LL . Address: !3 !R ��a� n �� 7�� 5,� City/State/Zip: � • ��m o u�ti , /�'1� oa 664 Phone #: �S "7�° —��o Ar,,e,_y,�o an employer? Check the appropriate bos: Business Type(required): 1.qd I am a employer with �. employees(full and/ 5. ❑ Retail or part-rime).* 6. ❑ Restaurant7Baz/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. [No workers' comp.insurance required] 8• ❑ Non-profit 3.❑ We aze a corporation and iu o�cers 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]* 11.❑ Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant ihffi checks box kl must also fill out the section below showing the'v workers'compeusatioa policy information. •'If tlte corporate officers have exempted themselves,but the wrporadon has other employees,a workers'compensation policy is reqnued and such an organizs[ion should check box#1. � I am an employer that isproviding workers'comp nsation insurance for my emp[oyees. Below is thepolicy information. Insurance Company Name: � �{� /��Q.� -�i��l,�o'GI pl�'Q � , Insurer's Address: � , �nc� ��(1_ � �-Q - i-�aX .L�QZ� �i,(,i�L ��'l CiTy/State/Zip: ��' Q�� . Policy#or Self-ins. Lic. # � � C �!- �� C � 25 �7 `��/Ts�Sh,xpiration Date: �� `�� • Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiratiou date). _ Failwe to secure cover�e_as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalries of a - - - — _ — - _ — fine up to $1,500.00 and/or one-yeaz 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 Invesrigations of the DIA for insurance coverage verification. Ido hereby certi nder thepains andpenalties ofperjury that the information provided above is true and correM. Si ature: � Date: << � E' ��. Phone#: gJ , b� '�� Official use on[y. Do not write in this area,to be comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(circie 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�