The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � c � � � °' � TQWN 4F YARMdUTH BOARI? OF HEALTH � �� -} APPLICATION FOR LICENSI�lP�B�IT,,, �i� �3 �D 1 �'=�. * Please complete fortn and attach all necessar�c2,ciE�ii�e' eY �er IS 2014. � Faiture to do so�vill result in the return�you�agp�i o p t. -- -T� � !-1rpT EST'ABLISHMENT NAME: � p/ i T Z cry� ' n; D: - � �_ LacaTlo�v��ss: � , � S r,n� -0�.6� �L.�: a��2 �q14 MAILING ADDRESS: oY1S�-ct c,� y!/ - {�� E-MAII,ADDRESS: {1 f? � ��_�- dWNE12.NAME: Y�- CORPOTtATION NAME (IF APPLIC LE): y� ��.,�, MANAGER'S NAME: S'�j�4,� ��e.0 TEL.#: �.��(-2�� N6�' MAILINGAT7DRESS: tSK, S�ince v+v 1iV� ;iv,7r,��t�-� .�,7 - �. � POOL CERTIFICATIONS: The paol supervisar must be certi�ed as a Paol Operatar,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification ta this form. 1. 2. Pool operators must list a minimum ai`two empiayees currently certified in basic wazer safety, standard First Aid and Community Cardiopulmanary Resuscitation (CPR), hauing one certified employee on prernises at all tirnes. Piease list the empioyees belaw and attach copies of their certifications ta this farm. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of bueiness. 1. z 3. �. FOOI3 PROTECTION MANAGERS - CEI2TIFICATIONS: All faod service establistunents are required to have at least one full-time employee who is certified as a Food Protection Manager, as definad in the Stafe Satutary Code for Faod Service Establishrnents, 10� CMR 590.Od0. Please attach capies of certification ta this application. The Fieaith Department vrill not use past years'records. You must provide new copies and maintain a file at your establishment. r. z. PERSON IN CHARGE: Each foad establislunent must have at least one Person In Chazge (PTC) on site during hours of operation. 1. 2. AI.LERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time ernplayee who has Allergen cerYification, as defined in the State Sanitary Code far Food Service Establishments, 105 CMR 590.Od9(G}(3)(a}. Please attach oopies of certification ta this appiication. T6e Heaith Department wiil not use gast years' reeards. Yau must provide new copies and maintain a file at your establishment. 1. 2, HEIMLICH CERTIFICATTONS: All food service establishrnents with 25 seats or more rnust have at ]east one employee trained in the Heirnlich Maneuver on the prernises at all times. Please list your employees trained in anti-choking procedures below and attach copies of ernplayee certifications to this form. The Health Department w'►Il nat use past years' records. I'ou must provide new cppies and maintain a file at your piace of business. 1. 2. 3. 4. _ _ RESTAt3RANT SEATING: TOTAL # OFFICE USE O1VI.Y L4DGING: LICENSE REQUIRED FEE PERMIT# LICF.NSE ftEQUIRED FEE PERMIT# LICENSF.'REQUIRED FBE PERMIT# S&B $55 CABIN $55 MOTtiL $110 _fNN $SS — —CAMp $55 SW[MMINGPQOL$ItOea. _LODGB $55 _ ;_ =TRAILERPARK $lOS _WHIFLLPOOL $IlOea FOOD SERVICE: LFCENSE RPQUIRED FEE PBRMI'I'# LICENSE I2EQUIRED FEE PERMIT# LICENSE REQ UIRED FCE PERNIIT# 0-IOOSEATS $125 .,_C6NTINENTAL $3S NON-PR6fIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —FtESID.KJTCHEN $&Q RETAIL SERVICE: LICE7VSE REQUIRED EfiE PT;RMI'T'N LICCNSE REQU[RED FEH PERMIT H LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $�Q >25,00(>sq R. $285 VEND3NG-FOOD $25 �QS,OOpsq.ft. $150 ��'�� _FROZENDESSERT $40 �TOBACCO $110 �b �� NAMECHANGE: $15 AMOUNTDUE _ $ ��a�C)CJ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t � ALIMINI5'CRATION Undex Chapter 152,Section 25C,Subseotion 6,the T'own of Yannouth is now requrred to hold issuance or renewal af any license or permit to operate a business if a persan or company does not have a Certificate of Worker's Compensation Insurance. THE AT"I'ACHED STATE W412KI:R'S COMPENSATION INSURANCE AFFTDAVIT MUST BE COMPI.ETED AND SIGNED, OR CER1'. 4F INSURANC'E ATTACHED OR WOR.KER'S COMP. AFFIDAVIT SIGNED ANI7 ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�, NC} MOT�LS AND OTHER T.,ODGING ESTABLISHMF,NTS TRANSIENT OCCUPAI�CY: For purposes of the limitations o£Motel or Hotel usa,Transient occupancy shall be limited to the Cemporary 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 mare than tivrty(30)days,and an aggregate of not mare than ninety(90)days within any six(6)mnnth period. Use af a guest unit as a residence or dwelling unit shatI not be considered transient. Occupancy that is subject to the collection of Room Oceupancy Excise,as defined in M.G.L. c. 64G ar 834 CMR 64G, as amended, shall generally be considered Transient. roaLs POC}L OPENING:All swimming,wading and whirlpoo(s which have been closed for the season rnust 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: Peaplc are NOT allowed ta sit in the paol area until the pool has heen inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate counl by a State certified lab, and submitted to the Health Departnnetrt three (3} days prior to �pening, and quarterly thereafter. PdOL CLOSING: Evary outdaor in�raund swimming paoi must be drained or covered within seven{7}days of closing. " FOOD SERVIC� � SEASONAL FOOD SERVICE OPENING: Atl food service establishments must be inspected by the Heatth Department prior to opening. k'lease contact the Health Depariment to schedule the inspectian three (3)days prior to openang. CATERING POLICY: Anyone who caters within tha Town of Yarmauth must notify the Yarmouth Health Department by filing the reqwred Temper�y-�'oad Servi�e Applicatian farm 72 hours priar to the catered event. These forms can be obtained at the Health Deparhnent,or from the Town's website at www.yaimouth.ma.us under�Iealth 12epartment, I7awnlaadable Forms. FROZEN DESSERTS: Frozan desserks must be tested by a State certified lab prior to opening and rnonthty thereafter,with samp(e results submitted to khe Health Department. Failure to do so will rasult in the suspension or revocatian of your Frozen Dessert Permit until the above ternis have been met. OUT'SIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),niust l�ave prior approval from the Boazd ofHealth. OUTDOOR COQHING: ` Oufdoar eooking,prepazation,�r dispIay of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annualiy from January 1 to December 31. IT IS YOUR R.ESPONSIBILITI'TO RETt..JItN 1'HE C4MPLETED RENEWAL APPLICATION{S}AND REQUIRED FEE(S}BX DECEMBEI2 I5, 2014. ALL RENdVATTONS Tp ANY FOOD ESTABLISHMENT, MOTEL OR PQOL (i.e., PAINTING, NEW EQUIPMENT,ETC.}, ML7ST BE REPQRTED'I'O AND APPRC}VEI7 BY TI-TE BOARD OF HBALTA PRidR TO COMMENCEMENT. RENOVATIQNS MAY REQUIRE A SITF,PLAN. vA��: �"��` �5� SIGNATURE: j�l!l�'�t� Y�T NA�� TL�:-3� t��r2�s�t P��i �s�� ftev_ ttf4)3174 � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurauce Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: r(J 0,1 �l''n-e� .�'✓�� TCIZ �oY�VB`Y1��7LG�. � Address: �� -�- 1°�R�� oW � a2G� City/Staxe/Zip: �� qA'lYl au>� � Phone#: ��'1�1��S�'q 103 Ar�e yo an employer? Check the appropriate bog: Business Type(required): 1.�J I am a emptoyer with � employees(full and/ 5. �Retail or part-rime).* 6. ❑ RestaurantBaz/Eating Establislunent 2.❑ I am a sole pmprietor 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] 8• ❑ Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment their right of exemprion per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other "Any applicant thaz checks box#1 must also fill out the section below showing their workeis'compensation policy information. '•If the cocpornte officers have exempted themselves,but the coiporation has other employees,a workers'compensation policy is required and such mm organization should check box#I. I am an emp[oyer that is providing worIkers'compensatian insurance jo/r�my employees. Be[ow is the policy injormation. Insurance Company Name: ��1��'q 7 ylfu 1�UYtCC �2'`�u/� l ��W��'1.,�� Q� �1�e��-- Insurer'sAddress: �� Z��Y�Y10L1�"1 � �Q .U�� J-��U CiTy/State/Zip: �Y "�' , rnfl - o� 6 0 �- Policy#or Self-ins. Lic.# �J�N�GI'\3 1 � �-� Expiration Date: �`2 I I � I 2G I C , Attach a copy of the workers' compensafion policy declaradon page(showing the policy number and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 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 forwazded to the Office of Investigafions of the DIA for insurance coverage verifica6on. I do hereby cenify,under the pains and penalties of perjury that the information provided above is true and correct. SiQnature• Y>�`Y� Date: ��'Z\ 1� Phone#: -�G� l� Official use only. Do not write in this area,to be comp[eted by city or tawn officiaL City or Town: Permit/License# Issuing Authority(circle 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