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Home My WebLink AboutApplication and WC ' G3G ' u� �-y a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PE�116-2D1S,3bw UEG U 3 1G I; . �, 35 P � * Please complete form and attach all necessary ocuments by Dece ber I S 2014. Failure to do so will result in the retuin of your'application p cke . LTH pEPT. ESTABLISHMENT NAME: K� 1 " Y�U�Y-� C� � _'ti'�=-TA iD: � � � � LOCATION ADDRESS: , -_ .�2�� i1�� -' � S' TEL.#: S�e' '�v MAILING ADDRESS: �. f-' �G � " �' � - E-MAIL ADDRESS: ' �/7y� � � � G /i �Yt : �� OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: S 6��(i iJ �( ��S�J,(/ TEL.#: �,��=-� � -� 2 zS MAILINGADDRESS: ��/=q, � .ic �, ' i ��/.�2�/hGv��;/J?�l- i. 2�(�� 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 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 empioyee 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 and maintain a file at your establishment. 1. Z• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 3. - �� - -- 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. 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 will not use past years' recards. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # - - - 9FRICE �.�SE�111�Fd_.� _ _ - - _ __ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 � MOTEL $l10 INN $55 CAMP $55 SWIMMINGPOOL$110ea [.ODGE $55 TRAILERPARK $]OS WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# , 0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 ��jQ >700 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE AEQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<Z5,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �JG.C:C� ****'PLEASE TURN OVERAND WMPLETE OTHER SIDE OF FORM***** /�L d ��L��7 aDMiNis�z��r�arr Under Chapter 152, Section 25C,Subsection 6,the Town of Yannouth is naw required to hold issuance or renewal of any license or pernzit to operate a business if a person or company does not have a Certificate of Worker's CampensaTion Insurance. THE AT'TACHED STATE W412KER'S COMI'ENSA"1'IOlY INSURANCE AFFIDA"VIT MUST BE COMPLETED AND SIGNED, OI2 C�R"I'. 4F INSCJRANCE ATTACHED OR WOI�ER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of yoia�permits. PLEASE CHECK F,PPROPRIATELY IF PAID: YES Nd MOTELS AND OTHF.R LODGING ESTABLISHi�iENTS TRAIVSIENT OCCUPANCY: For piuposes of the limitations of ivlotel or Hotel use,Transient occupancy shall be li,mited to the temporary and short term occupancy,ardinariIy and customarily associated with matel and hotel use. Trans3ent occupants must have and be able to demanstrate that they maintain a principai place af residence elsewhere. Transient occupancy shall generally refer to continuous occupancy ot`not more than thirry(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 conszdered transient. Occupancy that is subject ta the collection of Room Oceupancy Excise,as defined in M.G.J,. c. 64G or 834 CMR b4G, as arnended,shall generally be considered Transient. P4QLS PC}fitL OPENING.A11 swimming,wading�nd whirlpools which have been closed for the season must be inspected by the Health lleparCment prior to opening. Coi7tact the FIealth Department Co schedule the iuspection three(3) days priar to opening. PLESSE NOTP: Feople are NO'I`allowed to sit in the poo] area witil the pool has been inspected and opened. I'OOL VI'ATER'1'�+STING: The wat4;rmust be tesCed for p;�eudamonas,total coliform and standard plate counY by a State certified lab, and submitted to the Health Departrnent three (3) days prior to apening, and quarterly thereafter. POOL CLQSING: Every putdaor in graund swimmSng paol must be drained or cavered within seven{7}days of closing. F'OOD SI:RVICE SEASONAL FOOD SERVICE OPENING: All food service estabfishments must be inspected by the I�ealth Department priar to opening. Please cantact the Health Departmeixt to schedule the inspection three (3)days prior to opening. CATERING POLICY: .Anyone who caters within the Town of Yarmouth must notify the Xarmouth Health Department by fi.ling the required Temporary Faod Service Applicatian farm 72 hours priar to the catered event. These i'orms can be obtained at the Health Department,ar fram the Tpwn's website at www.vannouth.ma.us undez Health Department, Dawriloadable Forms. FROZEN DFSSERTS: Frozen desserts must be tested by a State certified lab prior to operaing and rnm�thly thereafter,with sample results submitted to the Health Department. Failure to do so wi11 result in the suspension ar revocation of your Frazen Dessert Pe;rmit until the above terms have been met. CIUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COIJHING: Qutdoor cooking,prepazation,�r display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETIJRN THE CO�VFPLETED REN�WAL APPI.ICATION{S)AND REQUIRIfi� P�E(S}BY DECEMBER 15,2414. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO`CEL OR POOL (i.e., PAINTINti, NEW F;QUIPMfiN1",ETC.}, MUST BE T2EPORTED Td AND APPRdVED BY THE B4AIZD OF HEAI,TH PRIQR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �/ � f �j —/� SIGNATURE: . _/,�/.Z(7� /E"fLc��._.- PR1NT NAME& TI'CLE:r��;(J ��t��-`�J/t1 ; ��C ,('UjFr✓';:.. I��C;^LfL �� itev,i t103174 � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: � (1 " �Q 0� �✓C�/� �iG Address: /�� ' �� -�� City/Staxe/Zip: '�,�� / �G��.�,17/�-G,�7�one #: 7�J��31�DtF�"C% Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-fime).* 6. ❑ Restaurant7Baz/Eating Establishment 2.❑ I am a sole proprietor or parinership and have no �. � 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 its officers have exercised 9. ❑ Entertainment their right of exempuon per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 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 the'v workers'compensation policy infomiation. *•If ihe cocporate officers have exempted themselves,but the corpora6on has other employees,a workers'compensation policy is required and such an organization should check box#l. 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: Policy#or Self-ins. Lic. # ExpiraUon Date: Attach a copy of the workers' compensafion policy dedaration page(showing the policy number and eapiration 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 $I,Sd�.60 and/or one-year imprisonment,as well as civil penalties In�ne�orm of a STO�WOIi�ORDEIZ at��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,.under the pains and pena[ties ofperjury that the information provided above is true and correct. Signature: ��/f��(��G/,TGZ�/i- Date• �/� ��> ' �y Phone#: � � Official use on[y. Do not write in this area,to be comp[eted by city or town offzciaL 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