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Home My WebLink AboutApplication and WC � � - N�acrz�E Prznu. � f` a � TOWN OF YAI2MOUTH BOARD OF HEALTH ' � �� APPLICATION FOR LICENSE/P�RIVF�T = �1,��- �. ,r _ 2O�4 " * Please com plete form and attach all necess a r y do c��s b y bece er 15 2014. Failare to do so will result in the return of yo applicahon p ketHEALTH DEPT. ESTABLISHMENT NAME: /ylAc�f ��Cov/sio.Js TAX ID• � �/ .�.�. LOCATION ADDRESS:�T/-� FiCvE 9�A✓E TEL.#:,��AGO -OL.S7 MAILING ADDRESS: ' � •< <S' �/a.c�r,o�rs� /�I ar GG r� E-MAIL ADDRESS: � �!'! � io�s'. C'o� OWNERNAME:�;i9.Cii /Y/�9l.C.�sE �/E.✓w/Ess� Lvo �E'f CORPORATION NAME (IF APPLICABLE): LOB h'E �/f'/A�wC.4E /�G MANAGER'S NAME: ,BAif.t �/ �� o�E TEL.#: cS.om E. MAILING ADDRESS: J'.om E POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pocl 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 Cazdiopulmonary Resuscitation (CPR), hauing one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form.The Health DepaMment will not use past years' records. You must prov►de new copies and maintain a fi►e 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 �ile at your establishment. 1. 2. -- r, i�I��I#ARFi�: -- -- -- - - - Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 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 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. 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 $SS MOTEL $110 —INN �$55 CAMP $55 _SWIMMINGPOOL$110ea LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $ll0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# � LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTIIVENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 =WHOLESALE $80 �Z — � —RESID.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 . <25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $I10 NAME CHANGE: $15 � � AMOUNT DUE _ $ 80�.p O ****'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•**' . ADMINISTRATION Under 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� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 sha11 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 whiripools 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 CLOSINGc Every outdoor in ground swimmir,g 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 Yannouth 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 obtamed at tYte Health Department,or from the Town's website at www.varmouth.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 Deparhnent. Failure to do so wiil result in the suspension or revocation of your Frozen 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. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishxnent is prohibited. NOTICE:Permits run annually from January 1 to December 3 L 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.),M[JST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: /I- �� — / `f SIGNATURE: PRINT NAME & TITLE: �S. �.�sE�'c.e/ 8ft/� A!l�.L Rev. il/03/14 � The Commanwealth ofMassachusetts Department of Industriat Accidents Offrce oflnvestfgations 1 Congress Street, Surte 1 DO Boston, MA 02114-2017 www.mrrss.gavldaa Workers' Compensation Iusurance Affidavit: General Businesses Applicant Information Please Print Leeiblv �� BusinesslQrganizat'ron Name: G°Fc�E ^ �'l�lr.�t-QE i.dG !/�r��'.t.�r,+E.�' a r.�.s rowR� Address:ai - .n �.c�vE.va/ �9✓ E p�t �G � City/State/Zip: cS'. YA.�7sa Sr�K A7,4' Phone #: ,,.ro8- 7G a - D G..S'T Are yoy.an employer?Check the appropriate box: Business Type(required): - —}��am aetnpioyeriviUi a�.��eFn�(eyees(fulland/ 5. ❑ Rekaii -- or part-time).* 6. ❑ Restauran2lBazfEazing Establishment - -- 2,❑ I am a sole proprietor or partnership and have no �, � p}�ce and/or Sales{incl.real estate,auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] &. ❑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 �4.� Manufacturing no employees. [No workers' comp. insurance requised]* �l.� Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, ,-�r with no employees. [No workers' comp. insurance req.J 12-L'_I uther .,��E,!'T�!"/B4,7p,�„ *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoimation. **If tha co�orate officus have exempted themselves,but the carporation has ather empIoyees,a workers'coa�pensation pulicy is reyuued mid such an organization should check box#1. I am an employer thaY is providing workers'compensation insarance for my employees. Be[ow!s the poltcy information. fnswance Company Name: .9if.BtGe .7 /N.S Insurer's Address: //p p C�(o ,J,�/ �iDt.-p�y y �„� City/State/Zip: ��/� � y ,/!'j,_q__paj /� q - �oIicy. o�2=m`s�I,ic.�€--'p"D�'`/raf.� �� f�—.- _ _. £�:piratioai3ate: —'�� ^--G�"�Y� - _ Attach a copy of the workers' compensation policy deciarafion page(showiag the pplicy number and ezpiration date). Failure to secure coverage as required under Sectian 25A of PvIGL c. ]52 can lead ta the impositian of criminal penahies af a fine up to$1,500.00 and/ar one-year imprisonment,as well as civil penalties in the form of a STOP WORIC ORI7ER and a fine of up to$250.OQ a day against the violator. $e advised thak a copy of this statement may be forwarded to tha Office of investigations of the DZA for insurance covetage verifica6on. I do hereby cert�,under the pains and penalSes af perjury that the informafiox provided�rbove is true and correct Si natur��,�� Date• //- .eto -/5� Phone#: �O e'�- �L O - plr.s' 7 Officia[use anty. Do not write in thds area,to be completed by city or town offzciaL City or Town: Permit/License# Issuing Authority(cirde one): l.Board of Health 2. Buzlding Department 3. CitytTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phane#: www.mass.gov(dia