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Home My WebLink AboutApplication and WC • i V♦T11 VP Z111�l1.1Lt111i Iti,Jril\u LP.��ll:+t>aY� � �� . a ICf3U4�Ely.'1 �� APPT.ICATION FOR LICENSE/PERMIT��1 ` �� i e 2�ns * Please complete farnz and attach all necessary dnc�zient�liy S 9, Faiture to do so wiU result in the retum of your applicataon pac ii DtF i . NAME O�ESTABLIS �S TEL. ' ' � LOCATION ADDRESS: MAII,ING AT3DRESS: ' OWNERT�IAME: � D E o S CORFOI2ATION N (IF APP I BLE)� � � ' ivfANAGER'S NAME; L. # MAiLING ADDRESS: POOL CERTIPICATIONS: The poo!supervisor must be certified as a Poal Operator,as required by State taw. Please list the designated PooT C}perator(s} and attach a copy of the certification to t7us farm. I. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Commuaity Cardiopuimonary Itesascitation(CPR). Please list these emptoyees belaw and attach copies of employee certifications to this farm. The Health Department will not use past years' records. Yoa must provide new copies aad maintala a file at yonr place of bnsiness. �, a. 3. 4. F04I7 PROTECTTON�vIANAGE1tS - CEI2TIFTCATIONS: All faod service estabtislunents are required to have at least one full-time employee who is certified as a Food Protecrion Manager, as defined in the State Sanitary Cade fox Food Service Establishments, 105 CMR 544.400. Please attach copies of certification to tlris application. The Health Department will not use past years'records. Yau mnat pravide new capies and maintain a Cile at yaur establishment. �. 2. PERSON IN CHARGE: Each food establishment must have at least one Persan In Charge (PIC} on site during hours of operation. �...�.�11�,�.��.�a.�t ( 2. .Yhs�'�l ��. �a s HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ar more must have at least one employee trained in the Heimlich Maueuver on the premises at all times. Please list your emplayees trained in anti-choking procedures below and attach copies of ernployee certificarions to this form. The Health Department wilt not use past years' records. Yo must provide w capies and maint�in a fele at your place of business. z.��"�.�.vf71CZ..�1'? 2. � L��..,�i C� 1C _ 3. � 4. RESTAURANT SEATINCr: TOTAL#�„L,_._._ OFFICE USE UNLX LODGING: LICENSE REQL7IRED FEE PERMIT� LICENSE REQUIRED FEE PERMIT# LICENSE REQi.11RED FEE PERMIT# _,_,_B&8 S55 „�CABIN $i5 _MOTEL SSS , _,,_INN SSS .,,_CA2�ii' S55 ,,�SV.'iMMII4G Pt}6L SSOea. LpE?GE SSS �TRAII,ERPARK $105 _WT31RT.,POOL S&Oea. FOOD SERVICE: LICENSE REQUIR£D FEE Pb1tMIT fl LICENSE REQiJ[RED FEE PERMIT# I.ICENSE REQLJll2ED FEE PERMI'I'# U-1p0SBATS E85 _.._CONTIN£NTAL S35 ,_ _NON-PROFIT $30 1 >ioosEaTs �lsa �ia'4� i cor�ioxvic. s�o -l6Ib-0� wzio�.Esnt� ssa RETAIL SERVICE: —RESID.KITCHEN S8U LICENSE REQURtED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMI7# �a50sq.ft $50 �>25,OOOsq.ft. 5225 „VENDING-FOOD $25 �QS,OOOsq.R. S80 .._FRdZENDESSERT $40 _TOBACCO $SS NAMECHANGE: Sii AMOt1NTDUE = S 22G . ob •�«•»pLEASE TURI^t OVER AND CdMPLETE OTHER SiDE OF PORM•*"`" ADMINISTRATION � � Under Chapter 152,Section 25C, Subsection 6,the Town of Yazmouth 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 ATTACkIED 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. PI,EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLLSHMENTS TRANSIENT OCCUPANCP: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarilq and customazily associated with motel and hotei use. Transient occupants must have and be able to demonstrate that they maimain a principal place ofresid�ce elsewhece. 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 Transiet�t. POOLS POOL OPENING: All swimming,wading and whirlpools wlrich haue been closed for the season must be inspected by the Health Departmentpnor to opening. Contact the Health Department to schedule the inspection three(3)dsys pnor to opening.PI,EASE NOTE:People aze NOT allowed to sit m the pooi area until the pool has been inspected and opened. POOL WATER TEST'ING: 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 CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(�days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme,nt by filing the required Temporary Food Service Application fonn 72 hours prior to the catered event. These forms can be obta�ned at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthiy basis by a State certified Iab. Test results must be sent to the Health Depaztment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit witil 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 ofHealth. OUTDOOR COOKING: Outdoor cooking,preQaratio�or display of any food product by a retail o;food service establishment is pro6ibited. __�._ _ � NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF1E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: � PRINT NAME&TITLE: � � `NL C�� 0925/09 � �'v � � ` • � The Corurnonweatth of Massachusetts DeFartr+reat of Lndusrriert Accidcnts MNCfM� 611D Wnshingtaa Street, fh Fioor Boston,Mass. 02111 Warkers'Compe■aaHoa fasarsnte AfSdsvit:Baildieg/PtambieglEleMrical Coetraetars �'..w��,._r.w�li�M• . � �iiP��T� � . . . �• �c��C.�c`�r___ — address: ,.^. ..... ...... . � ci.� � state' zilL'—_ oh"""� � . woilc site losazion ffull actdresKl' � � I mn a 6omeowaet perfamtinq aD work myse[f. ProjectType: ❑New C.�sttucfimt QR�odet I am a sole�propriecor and Lave no oce wocking in any�capxity. ❑Building Adlitioa [] t am an anplayer providiog waicers'compeasation for my etnpbyees wrrdcing on t6is job. com � ame: � . . ,.. -�. _... ._ . .. . . . . .. :.. .. . . . .. . . _. . . ��' _ cicv- � . . . � � oiuue#c � . . . . � � s�� .. . �.. i..: n.y. .�.. . - �'i'N sf..Y'k. .cTf� k'��'Yv�T.N�'A3y�t-�M'�AtN',Nn:Y. ❑ i am a sote proprieAor,ge�csl castractar,or i�eewaer(careti one)and have hit+ed the coMractas listed bctow wlw have. Lde fallowing ww�kas'compeasation polias: . � �• -. . . . � . . _ � . . . -w•-�• � -- � I�tY• . . , - � � � o1lNe$' . . ... . . , , . ��l�'!'K!G0. � � � . . nei c"s..,4�.v - .- - � � . . _ —. _ .,. . � Yi� ,._'`y�'�� '��'_ �AA�r�. �y ' . . . . . . . . . . . OWYlY' . . . . . _ . � . .. �.". � _.�.� . ,, ..�.:��. . , fT':.1:� N G ?,?as:m.d3, 7z+ :�;..ua^ic'�'„�;.�+."i.i�.�Ti.�`.��,*�:•' F.Krc a uc.e oam.epe...�q.6ea.der seew.l5a.rntGi.us n.Wa b IYe I�ps�itlr:.raY�Yd tmMn.r.4e.p a sl,seae+aNar wepcyn'�tm wdl7udA pea�a h He b��f�S'FOI'WORKUkDER.atl a iea[S1M.M edrya�Mst�c.i odaa4r3 tl�• c�pg�[IWt14atMlYgleNrlmdeAMHCOeketl�MNtlM.INAIYwreaNengCrplpoltlH. � - . � � . . � !b hm6j ' weter Me awdP�'w�H�'afP+�'�9+a!dirt Bis iwjenn�lon proAAed abane&mre a�d os�►ar.t- ,q ("]/ � . f i `�' . '_'" V ..._ _Ihx �,;�� tw1 '" �� St1 ff 7�'o�-'jt�C��f ��eid�acul� MrfwriteilWattabheaHpltln169.dh�rY+�t��cid. ,. �� -� . � �i � � Bprd . ❑tl�.dc#�a4m@elnebne�ed .. .� � .. . . , . . .. ❑Ne+MYDepNmut �tpect�a; � pt��eF; . �IOtles tmiodSytTOWI . . � . . . . NOTICE NQTlCE TO TO EMPL4YEES EMPLOYEES • The Commonweaith of Massachusetts � QEPARTMENT C1►F INDUSTRIAL ACCIDENTS � 60Q Washington Street, Bastan, Massachusetts 02111 617-727-4900 — nttp://www.state.ma.us/dia � As required by Massachusetts General Law, Chapter 152, Sectians 21, 22, i� 30, this witi give � you notiss that 1 {�s} have provided far pa}ment to our injured �rnpiUyees unrt�er the above m mentioned chapter by insuring with: � a z m uavmrnun FrtxF rnitArmAwCE COMPANY � N NAME 4F INBURANCE COMPANY .� o ONE PARIt PLACE, 3d0 S. STATE ST. , 7TH FLOOR N n.�..w�,n*.+ � 1�7(I') � ADDRESS OF INSURANCE COMPANY � � 48 4VEC NL4612 06/01/09 g pOi.ICY NUM8ER EFFECTIVE DATES �DOWLING & 0'NEIL TNS AGEaICYlPHS 301 WOODS PARR DRIVE � CLZNTOI3 NY 13323 �NAME OF !N$URANCE AGENT ADDRESS PHQNE � ZDOM, SNC. 1329 I20UTE 28 � 60UTFI YARMOL7'�'i3 MA 026&4 �EMPLOYER ADDRESS � a� �EMPLOYER'S WORKERS COMPENSA710N OFFICER (IF AN7) DATE � � � MEDICA� TREATMENT �The above named insurer is required in cases of personal injuries arising out af and in the course of employment �to furnEsh adequate and reasonable haspitai and medicai services in accordance with the provisians of #he �Workers Compensation Act. A capy af the First Report of Injury must be given to the injured employee. The �emptayee may setect his or her own physician. The reasanable cost af the services provided by the treating �physician witl be paid by the insurer, if the treatment is necessary and reasonably connected to the wark related �injury. In cases requiring hospitai attenition,empioyees are hereby nat�ed that the insurer has aRanged for such �atteMion at the � : � �NAME OF HOSPITAL ADDRESS � � TO BE Pt�STED BY EMP�C?YER Form WC 88 20 01 C Printed in U.S.A. .