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Home My WebLink AboutApplication and WC . . �3-iZ .i v�� P�2t� a . TOWN OF YARMOUTH BOARD OF HEALTH G3C�C�C��`/fSDD �� APPLICATION FOR LICENSE/PE'�RM,� c2(�01 � �. ✓utL O1 �"` * Please complete form and attach all necessary�oct�ine C$"b�Dec mber IS 201��14 ` Failure to do so wili result in the retu�n of your applicahon ack��TH DEPT. ESTABLISHMENTNAME: ��,/?r �� !��-��, f<•�—�%t=,-�, �T�� TAXID: LOCATIONADDRESS: /-/` � !� 'i %lt�-c " `�T� ,l�iaFe i,�'� i'�i� f//� TEL# �Cs;-- ;9��2ri/ MAILING ADDRESS: ,� �� -� ,� � E-MAILADDRESS: j(ct�«<�--�^,�� "c %�Fc'f<<� Itf �" ,. OWNER NAME: CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: � y,/�� -� � L -L_ TEL.#: � MAILING ADDRESS: POOL CERTIFICATIONS: _ _Thaponlsu�tet�vis�musibe_�ertified as_a Pool Operator, as required by State law. Please list the designated Pool Operatar(s) and attach a copy of the certification to this form. 1. ��l//t 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. l. Z• 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 a d maintain a file at your establishment. L ��j� � � 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �f j:t 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. ��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 HeaUh Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �(/�i� 2. 3. 4. RESTAURANT SEATING: TOTAL# �� VY� � I�= C� ( J OFFICE USE ONLY ��_� � i�,,��_ � �c'� 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 �TRA[LER PARK $105 j� _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >]00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 —<25,OOOsq.ft. $150 —FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I O '�J. G'O - *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADNIINIS'7'RATIt�N Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth is now required Yo hold issuance or renewal af any licensa or permit to operate a business if a persan or cornpany daes not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COIYIPENSATIQN INSL�t2ANCE AFFIDAVIT MUST BE COMPLETF.D AND SIGNED, OR CI�RT. OP INSURANCE ATTACI-lED OR WORKER'S COMP. AFFIDAVIT SIG7VED ANI3 ATTACHED Town of Yar[nouth taxes and liens tnust be paid prior to renewal or issuance of yor�r permits. FLEASE CHliCK APPFLOFRIA"IBLY IF' PAID: YBS�_ NO_. MOTELS AND O'THE12 LOD�ING ESTABI.ISI�MENTS 'LRANSIENT OCCUPANCY: For purposes ofthe limitatiotis of'Motel ar Hotel use,Transient occupancy shall be limited ta the temporary and shart term occixpancy,ordinarily and customarily associated with motel and hotel use. I"ransient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewherc.Transient occupancy shall generally refer to continuQus occupancy of not more than thirry(30)days,and an aggre�ate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a res'rdence or dwelling unit shall not be considered transient. Occupancy that is subject ta the collection of Room Occupancy rxcise, as defined in M.G.L. c. 64G or 830 CMR 64Cr, as amended, sha11 generally be consadered Transient. P4t7LS P40L OPENING:All swimming,wad'u�g and whirlpools which have been clased far tha seasan must be inspected by the Health Department prior to opening. Coratact the Health Department to schedule the inspection three(3) days prior to opening. PLEASB NdTF.,: People are NOT allowed to sit in the pool area until the poot has been inspected and opened. POf1L VVATER'fESTING: The water must be tested£or pseudamonas,total coliform and standard piate count by a State cerTified lab, and submitted To the Health DepartmenC three (3) days prior to opening, and quarterly thereafter. P4tDL CLOSIIV�G:Every c��zidoar in groua�swimming�aol must be drained cr covered within se��en{7)days af closing. FOOD SF.RV[CE SEASONAL FOOD SERVICE OPENING: All faod service establishments must be inspected by the Iiealth Department prior to opening. Flease contact the Hea1Ch Dc�parCrnent to schedule the inspection tht�ee (3}days prior to apening. CATERING POLICY: Anyane who caters within the Town uf Yatmouth musC notify the Yarmouth Health Department by filing the reqntred Temporazy Food Service Applicatian form 72 haurs priar to the catered event Thesa forms can be obtained at the Health Department,or from tlle Town's website at www,varrnouth.ma.us under Health Department, DownFoadable Forms. FROZEN DI�SSERTS: Frozen desserts must be tested by a State certified lab priar to opetaing and monthly thereafter,with sample results submitted to the Healkh Department. Faifure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the above tercns have been met. OITTSIDE CAF�:S: Outside cafes(i.e.,outdoor seafing with waiter/waitress service),must have prior approval from the Board ofHealth. _ C)UTDOOR COOHING: _ ._ . _ Outdoor cooking,prepazation,or dispIay of any food product by a retail or food service estab&shment is prohibited. NOTICE: Pezmits run annually from 7anuary I to December 31. I't'IS YOUR I2ESPONSIBILITY TO RETURN THE C4MPLETED RENEWAL APPLICATIC}N(S} ;�ND RF,QUIRT;I3 FBE(S}BY DECEMBER 15,2014. A,LL RENOVATIONS TQ ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.}, MLJST BE REPC)RTED'I'O AND APPROVED BY THE BOARD QF HEALTH PRIdR TO COMMENCEMENT. RENOVATIONS MAY REQU RE A SITE PLAN. i � ' ��" 1� DATF: i�! � !S SIGNATIJRE:�� ,��r� .�'L�`�'�-�:�f� PRINT NAME& TITLE:_ � i f� ��r'c'ti�� i�,�'��t� Yl- ��1 t � Rev.11f03174 � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite I00 Boston, MA 02II4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�plicant Information Please Print Legibly Business/Organization Name: ��5; � , � F ��i �i` i��'�C . �� -- , Address: /i%,�' l�'i/�•z�' L�� City/State/Zip: � ��« � �� ,� �� C',` � Phone #: .��'.� ��%� .�� ( / Are you an employer? Check the appropriate bos: Business Type(required): 1.[f Iam a empIoyer witfi--" "---'`emp�loyees (full and/ 5. ❑ Retail . or part-rime).* 6. ❑ RestaurantlBaz/Eating Establishxnent 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) 8• ❑Non-profit 3.❑ We aze a corporation and iu officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* I 1.❑ Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. msurance req.] 12.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that isproviding workers'compensation insurance for my empLoyees. Below is thepolicy information. Insurance Company Name: Insurer's Address: City/State/Zip: ,;{[`�;Z �`- '7.�[�C"� Policy#or Self-ins: Lia # _ __ _ ___ _ Expi�ation�ate�__ --- -- --- Attach a copy of the workers' compensation policy declaration 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 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 Invesrigations of the DIA for insurance coverage verification. I do hereby certify,u jer the pains and pena[ties ofperjury that the information provided above is true and correct. Si ature: ��g k �F� L - / ,��-ZC,= Date• /.-��i[�'f Phone#: ��f1 :�j�� ,�-C^ I f Official use only. Do not write in this area,to be completed by city or town 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