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Home My WebLink AboutApplication and WC �� . � � TOWN OF YARMOUTH BOARD OF HFrt�,L`�'�I` �� `S � ocr � o zu�3 ,/ . �� APPLICATION FOR LICENSEaPE��32�0,14 L * Please complete form and attach a11 neces�y o i�menfs by Failure to do so will result in the retum of your application packet. ESTABLISHMENT NAME: b �S , LocaTiorr aDDxEss: t 32�1 Rte� 8' TEL.#: � 7�6 -/�O MAILING ADDRESS: � ?i,�q �fi2 � 'LQ' y( .�US}� /Yl A O�Z(o(vt� E-MAII,ADDRESS: 11 OWNER NAME: �,��gM ��' Yfl'1Q, CORPORATION NAME (IF APPLIC BLE)• O MANAGER'S NAME: � VI TEL.#: — /O (p MAILING ADDRESS: l `' 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. 1. 2. Pool operators must list a minimuxn of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a116mes. 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. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-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 wiil not use past years' records. You must provide new copies and maintain a file at your establishment. i. I�3� I�o rn �p v�re ncc.n t 2. I,J t.�.(�a m Si.�.Y �v r�nc�n� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of o,peration. �.J,,J��iccnn �r;tyljr�na.�1- a.��►� ��V�C� �a 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. i. �.� � ��x_�m �urPr�.na.�,I a. �''tCc,�k P`lu.�P Iw HEIMI,ICH 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-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 file at your place of business. i.�, 9.�n (Yl�ess r �.� � z. `rP.v n �cc�-n�m 3. � l(Z..l�' t6.2� �, 4. 1� (�C�ce..iC RESTAURANT SEATING: TOTAL# I,�Q� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMING POOL $SOea _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 CONTINENTAL $35 NON-PROFIT $30 �>]00 SEATS $160 ' 14-cn� �COMMON VIC. $60 �a�14=Cc'L WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 =�ROZEN DESSERT $40 —TOBACCO � $95 NAME CHANGE: $I S AMOUNT DUE _ $ �aC' �C G •****PLEASE TORN 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 ta�ces 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 shall 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 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 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools 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 azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. ___ __ __ __ _ - - - r ��s�Kvr -_ _ __ _ SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Deparhnent to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth 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 obtained at the Health Department, or from the Town's website at www.yarmouth.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 Department. Failure to do so will 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 establishment is prohibited. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEME T. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �U��3 SIGNATURE: �y� _ '� '�`� PRINT NAME &TITLE: (.l� � � �I QlYI �rQr��1� ' UWn� �e � Rev. 10/OS/13 � � � The Commonwealth ojMassachusetts Department ojindustria[Accidents • Offzce oflnvestigations ' 1 Congress Street, Sudte 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensatioa Insurance Aftidavit: General Businesses Anulicant Information Please Print Le¢iblv Business/Organization Name: �— �(�Y� 1 V�C . Address: `�j 2,�[ �1" 2� City/State/Zip: '�0� YV�Ik o Pho'ne#: Cjb� `�(06 - I,OD� Are ou an employer? Check the ap ropriate bos: Business ype(required): 1.� I am a employer with �Q'Z�employees(full and/ 5. ❑ tail or part-iime).* 6. RestauranVBazlEating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ 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.❑ Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. inswance req.] 12.� Other *Any appGcant tha[checks box#1 must also fill out the secfion below showing their workers'compensafion policy information. •*If t6e cotporete officers have exempted themselves,but the corporarion has o[her employees,a workers'compensation policy is required and such an organizaflon should check box#1. � � � � I am an employer that is providing workers'compensation insurance jor my employees. Below is the policy 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 eapiraHon date). Failwe to secure coverage as required under Section 25P,ofMGL"c.1�2 can lead to fne imposition oi criminai penalties 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cenify,under t epains andpenalties ofperjury that the information provided above is true and correct. Simature:��,� �La�..i�il/{�A �� Date: ��I 3�I �3 ..� _. ... _ Phone#: �� od' ��U Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: y�R-ht o uT�!- Permit/License# Iss ' u ircle one): 1. oard of Healt . Building Department 3. City/Town Clerk 4.Licensing Board 5. 5electmen's Office 6.Other Contact Person: Phone#: b�8-348-3a�! k !Z'�(�/ www.mass.gov/dia - flct, 34. 2413 9:29AM Dov�l ing & O�Nei I Na 1388 P. 1 12 (PoticyProvlslons: �C ao ao 00 8Y �4 B ' NL iNFORMATION PAGE w�� WQRKERS COM►PENSATlON APtD ENIPLQYL-'RS UA$ILITY POLICY INSURER; �TFORD FIRE INStYRANCB COMPANY QNE 11ARTFORD PLAZA� HAt1TFOhD, C;OQJNBCTIC[ri' 06155 NCCICompanyNumber. i�26s iHE Campany Cflde: 2 HARTFORD surra LAR9—RBIt6YYAE POLICY NUMBER; pe aBC N�4eia o9 Provious Paitcy Nurnber: oa �ec �caaia flOUSIHG CODE: DW t. Named t�suted and Maipng Address: ZmM. TNC. {No.,Strgel,Tawn, St�s,Zlp Codej {SEe �zdDT) z3as xou�s ae FEIN NulflbEt: SOtTx't[ XAftMbUTH, MA 02669 Stete Idenfificetion Number�s): vfn, 7he Namsd�nsurod is: ��a2rax BU8lness of Named Insured: FAMILY STY'LE RE5TAURANT - PPAti Oth�arworkpfacesnotshownebove: i�� Ro�'E as 54SST8 YARMIX7TH MA 02fi64 2. PoIlcyPerlod: From o5/ox/za To os/oi/ia 12�01 a.m.,Slandard tima at ihe insured's maHing address. ProducerBNeifre: �LING & Q'NEIL INS AQENCYjPHS 30� I�C%Y(iR PA{tK fiRTVF. CLINTON, NY 13923 PiOdUC6►�6 fiAfIC: 0882 33 IssUiOg OfflcB: THE RARTFORD 301 NOOAS PARK DRTVE CLZNTLIN NY 11323 l066) 467-9T30 Tatai Estimated Mnuai Premlum: Ss,soa Deposft Pra�m: pollcy Mlntmum Premlum: Saie nta AudkPwlad: �� tnstatimentTerm: The poiicy is nol bindir�unlesa countersiyned by our authorized represenlatke. GI'��c�T` Codt`',r,�,�, Countersigned by 04/20/13 A�thorized R�resentaliYe [YaEe Form 1NC 04 00 41 R {1� PrMted in U.3.A. Papa 1 (CaNin�d an ne�R page ProceseDate; oa/zo/is PoIlcyExplretlonDate: oB/oi 1a