The URL can be used to link to this page

Home My WebLink AboutApplication and WC� S,�+noN Rw.�uoco • a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PLIAJVI `P,- ° -�S'��d��° * Please complete form and attach all necessary do��y�ec tbe :�i� fl 14 Failure to do so will result in the rehim of�oue appkcatiotr cket. ESTABLISHMENT NAME: at�.n Avc 5u�� T LOCATION ADDRESS: y�� Sir.r:�n ,►�ve. g, yYtMONO. ,MA o2664 TEL.#: �og�6�9- 3633 MAILING ADDRESS: �iu•..� E-MAIL ADDRESS: wcic•«. '.L8\ � vd�.oa.cow. OWNER NAME: M. tik� CORPORATION NAME (IF APPLICABLE): 1Y1KW r�Sone . TNL MANAGER'S NAME: �it 6w+ (,��1�.�,., TEL.#: CM��H�6 ' 3 3 SS MAILING ADDRESS:�,eP14?.0 CI.A . W, `lor�.w.A , MA o267� � i POOL C�RTIFICATI4NS: _ _�, _ . 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 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. 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 Establistunents, 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• '` __— P�R503d-�N CI3ARGE: - _...__ _- -- __ _ — .� Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I 1. 2. ALLERGEN CERTIFICATIONS: All food service establishxnents 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-choking procedures below and attach copies of employee certifications to this form. The Health Department wi11 not use past years' records. You must provide new copies and maintain a �te at your place of business. 1. 2. 3. 4. _ - _ �. RESTAURANT SEATING: TOTAL # _ - -- _ i 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 TRAILERPARK $105 WHIRLPOOL $IlOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS $125 _CONTIIVENTAL $35 NON-PROFIT $30 —>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 . —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L<50 sq.ft. $50 c� I fa >25,000 sq.ft. $285 VENDING-FOOD $25 QS,OOOsq.ft. $150 _FROZENDESSERT $40 —TOBACCO $I10 � NAME CHANGE: $15 AMOUNT DUE _ $ SO. On � � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"**** ADMINISI'RATION Under Chapter 152,Section 25C, Subsection 6,the Town af Yarmouth is now required to hold issuance or renewal n£any license or permit tn opezate a business if a person or company daes not haue a Certificate of Worker's Campensation Insurance. TI3E ATTACHED STATE WORKER'S COMFENSATION INSURANCE AFFTDAVIT MUST BE COMPLETED AND SIGNED, OR CI"sRT. QF INSURANCE ATTACHED OR W(3RKER'S COMP. APFIDAVIT SIGNBD AND ATTACAED� 'Town of Yazmouth taxes and liens rnust be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAtD: 'YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS 'TRANSIENT OCCUPANCY: For pwposes of the limitations oFMotel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinarily and oustomaxiiy associated with moteI and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principa] place of residence elsewhere.Transient occupancy shall generally refer to continuaus occupancy of not rnare than thirry(30)days,and an aggregate of not rnore than ninety(90)days wilhin any six(6}month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that as subject to the callection of Roarn 4ccupancy Excise, as defined in M.G.L. c. 64G or&30 CMR 64G,as amended, sha11 generally be considered Transiant. PO4LS POOL QPENING:All swirnming,wading and whirl�aoois which have been closed for the season must be inspected by the Health Department prior to opening. Contact ihe Health Dapartrnent to schedule the inspection three(3) days prior Eo apening. PLEASE NOTE: Peaple are NOT allowed to sit in the pool area until the poai has been inspected and apened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliforrn and standard plate count by a Stata certified lab, and submitted to the Health Department three (3} days praor to opening, and quarterly thereafter. POfl�CL4SIN�:Every outdcwr in ground swimmir.g pool must be drained or covered within seven{7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENIN(�: All faad service establishments must be inspected by the Health Department prior to opening. PIease contact the Iiealth Deparlment to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who catexs within the Town of Yannouth must notify the Yannauth Health Department by filing the required Temporary Food Service Application farm 72 hours prior to the catered event. These forms can be obtained at the Health Department,ar from the Tnwn's website at www.yarmouth.ma.us under Health Department, Dowziloadzble Forms. k'ROZEN DESSERTS: Frozen desserks must be Yested by a State certified lab prior to apening and monthly thereafter,with sarnple results submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Frozen I7essert Permit until the abave terms have been met. OiTTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appcoval from the Board of Heatth. ;r-__ fJLIT1lQf1R COQKIN�:_._ _ . _ _ _ _ _ ._ _ — -- — _ Outdaor cooking,preparation,or display of any food product by a retail or food service establishmenf is gro6ibited. NOTICE:Permits run annualiy from 7anuary 1 to December 31. ITTS YOUR RESPONSIBiLI`T'Y T4 RETCTRN THE COMPLETED RENEWAL APPLICATI4N{S}AND REQUIRP.D FEE(S}BY DEGEMBER 15,2414. ALL RENOVATIONS Td ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., Pt1FNTING, NEW BQUIPMENT,ETC.},MUST BE REPORTEI}'CO AND APPROVEL7 BY TfiB BOAII.D OF HEALTH PR10R TO COMMENCBMENT. RENOVATIONS MAY REQUIRE PLAN. DATE: 11-26- {K SIGNATURE: ' PRiNT NAME& TITLE: ►�l�fiY4 W GtJ�k,� �°Ks,^�4.r/o�,,,� Rev. IfJ03114 � The Commonwealth of Massachusetts ➢epartment of Industrial Accidents Office of Investigutions 1 Congress Street,Suite 100 •+ Boston,lVlA 02II4-2017 www.rrrass.gov/dia Workers' Comgensation Insurance Affidavit; General Businesses A�plicant Information � Please Print Leaiblv Business/OrganizadonName: M►i�„! > s,,�,s ",�"'�fG ,�/bf„ 'STwt�v, A� 'S�,oc� Address: '"�°33 �t � U� A.� CitylStatetZip: �. Y��meA� MA a,`�,bb�s Phone#: (�v81 (, 79-3633 _ Are on aa empFayer?Check the appropriate box: Busioess T ype{required}: 1. I am a emplayer with '.5 employees(full and/ 5. ❑Retail or part-time).* 6. �RestaisanUBaz/Eating Establishment 2.❑ I am a sole gragrietor or partnership and hava na �. �p��d/or Sales{incl.real�taze,autq etc.} employees working for me in any capacity. I jNo warkers'comp.insurance required] $� ❑�QII-profit 3.❑ VJe aze a corponrion and its officers have exacised 9. ❑Entertainment their right of exemption per c. 152,§I(4},and we have 10.�Manufactiuuig i no emplayees. jNo workeis' comp.insurance required]x I1.0 Heatth Care 4.❑ VJe aze a non-profit or�twizalion,staffad by volunteers, witta no employees. [No warkers'comp.ine�,rance req.] 22.0 Other "Any applicant that checks box#1 must also Sll out the sectioa below s6owing their workers'campensation policy infonnation. ��'�� •*Tf ffie carporate officc�s have eaeempud ihemsetves,but the coipacatian has oth�emp3oyces,a workers'cvmpensatioa policy u required mmd such sn ��, organization should check 6ox#1. � I am an employer that is praviding workers'compensatzon insurance fnr my employees. Be1ow ic the poGcy informmYon IusuraziceCompsnyName: C7LaoT } Tns 1lat�cv - Insurer's Address: r1.6 P�w�swor'�'� S� City/State/2ip: «; �,,� c�3.66`I Policy#or Self-ms.i,ic.# T A NA - a a�s u��-�-�4 Eacpiration Date: (�-/'/S Attach a copy of the workers'compensafian petGcy declaratiou paga(showing the policy number and ezgiration date}. Failure to secure coverage as required under Section 25A of MGL c. 152 can]ead to the imposition of orfminal penalties of a fine up to SI,500:00 and/or one-year imprisonxnem,as well as civil penallies rn the form of a STOP WORK qRDER and a fine of up to$25Q.40 a day against the violator. Be advised that a copy of this statament may be£orwarded to the Office of Investigations of the DIA for insurance caverage verification. I do hereby certzfy,r �the paires and penaXties of perjury that the information providei!above is hue and correct G;o„afi+��..��'� ' Date: ll'.2G"-1 Y P on #: vX l �`3C'.� Offuial ase an[y. Do por write in tkis area,to be comp[eted by city or town o,�iciaL CiYy or Town: PermiU[,icense# Issuing Authority(circle one): 1.Bosrd of Health 2.Building Departmenf 3.CityJTown C►erk 4.Licensing Board 5.Sefectwen's Office 6.Qther Contact Persou: Phone#: www.m8ss.govldia � �� NflTICE , NOTICE TO o TU EMPLt�YEES �� EMPLQYEES `L .�� SYy v The Commonwealth oF Massachusetts DEPA►RTMENT UF IlYDUS�7tIAL ACCIDENTS 600 Washingtan Street, Soston, Massachusetts 02112 b17-727-490!) — http:/Iwww.mass.gov/dia As re uired by Massachuseus Gemerai Law,Chapter 152,�:tio�21,22 Bc 30,this will give yau�rtice that I�we) have ptcrvicie�d Car papment to our in�uced emptoyees under tl�e abave mentroaed chapter by msurwg with: THE TRAVELER5 INSURANCE C�PAFiIES NAME OF INSURANCE COMPANX P.O. 80X 1450 1QIlDi.FBORO MA 02344-145(! a�nxFss a�nvsu�,rrc�ca�,� (IAUB-9A95947-0-14) {T6-Of-i 4 T(J 06-01-15 P(7LICY NUMBER EFFECTIVE DA'TES �� OCEArPOTNT INS AGENCV 26 BOSNN�2TH ST ..�� BARRINL;T�i RI 02806 NAME OF INSURANCB ACrENT ADI7iRE55 PIiONE# � WAKIM ENTERPRISES INC 43S SFATIOPI AVE . SEE ENDORSEl�NT WC 99 � pt � $OUTH YARMDUTH � MA 02664 BMPLOYEi2 ADDF2ESS � � EMPLOYER'S WQRKER5 COMPEI3SATIflN QFFICER(IF ANY} DATE � � MEDICAL TREATMENT � The above named insurer is required in cases of personat injuries arising out of and in the course of � emptoyment to furnish adequate and reasanable hospital and medicat services in accordance with the � provisions a£ the Workacs' Ctam}�ensatiaa Ack. A capy of the Pirst Report oE Tn}ury must be giv�en to the � injared employk:e. The employee may select his or her own physician. The reasona6(e cost of the services � provided by the treating physscian witi be paid by Lhe insurer, if the treatmenk is necess�ry and reasonably _ connected to the work retated injury. In cases requiring hospital attention, employees are hecebg notified that the insurer has arranged for such attentron ak the �°"� �; � �'�" � ��.# �t�: � �. � . . �.^� � . � ��^"� ��`,�°` NA.ME d�HOSPTTAL � ! ADDRFSS Q'� „� ,,,�p,�2 TO BE P4STED BY EMPLUYER