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Home My WebLink AboutApplication and WC . . Pv.r�es Paaa o�s E d TOWN OF YARMOUTH BOARD OF HEALTH ��d��D � � APPLICATION FOR LICENSE/PE T� '2 1 � �, UtG i 5 `1014 �� :.- * Please complete form and attach all necessary do nfs �ce er 15 2014. Failure to do so will result in the return'of yo�a�plieation ewEqLTH DEPT. ESTABLISHMENTNAME: ID: - �� LOCATIONADDRESS• � e,,��e ,�� ' ��Y�+�,�c, 1��3 TEL#•5�� 350 MAILING ADDRESS: 'P t7 � ou �F� 1�� A-�n�Qi�i-r VV�Ff1- �,z� 47 E-MAII,ADDRESS: ln � o� �n�.�.�s,�-i w�� . ��f^-- OWNER NAME:�_��c � � i-F��'-�-�`� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: -�A-�ti� TEL.#: S"b� '7�D 3�l�O MAILING ADDRESS: S 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 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 wi11 not use past years'records. You must provide new wpies and maintain a file at your establishment. L 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. 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 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. RESTAURANT SEATING: TOTAL# �_ 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 SWIMMINGPOOL$110ea LODGE $55 TRAILERPARK $105 _WH[RLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �I -�lU _CONTINENTAL $35 NON-PROFIT $30 . >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. $I50 �FROZEN DESSERT $40 �"� _TOBACCO $I10 NAME CHANGE: $l5 AMOUNT DUE _ $ / �5-nC� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"**�G� T �Zk� �� c?r� zo43 �a-/'s�� ADMINISTRATION iJnder Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmauth is now required to hold issuance or renewal of any license or pernut ta operate a business if a person or cornpany does not have a Certificate of Worker's Compensation Insurance. TFIE ATTACTIED STATE WORKER'S COMPEN3ATION INSUTtANCE AFFIDAVIT MUST SE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR � / WOR.KER'S CdMP. AFFTDAVIT SIGNED AND A'I'TACHBD V Toum of Yaimouth taxes and liens rnust be paid prior renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NQ MOTELS AND OTHER LODGING ESTABLI5I�MENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transiant occupancy sha11 be limited to the temporary and short term nccupancy,ordinarily and customarily associated with motel and hote[use. "]'ransient occugants znust have and be abla to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy skall generally refer ta 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. LJse of a guest unit as a residenoe or dweiling unit shall not be considered transient. Occupancy that is subject ta the collection of Raom Occupancy Excise, as defined in M.G.L. c. 64G ar$30 CMR 54G, as amended,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the seasan must be inspected by the Health Depaxtment prior to opening. Contact the Health Department to schedule the inspection three(3) days prior ta opening. PLEASE I3Q'I`E: Peaple are NOT allawed to sit in the pool area until tha paol has been inspected and opened. PQOL WATER TESTING: The water must be tesfed for pseudomonas,total coli£orm and standard plate count by a State certified lab, and submitted Co the Health Departrnent three (3) days prior to open'tng, and quarterly thereafter. P40L CLOSING: Every outdoor in graund swimm3ng pooi rnust be drained or cavered wathin seven(7)days of closing. FQOD SERVIC� SEASONAL FOOD SERVICE Ok'ENING: All food service estabtishments must be inspected by the Health Department prior ta openiug. Flease contact the Health Departrnent to schedule the inspection three{3) days prior to openittg. CATERING POLIC'4': ' Anyone who caters within the Town af Yarmouth must notify the Xarmouth Health Deparhnent by filing the required Temporary Food Service Applicatian form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or frarn the Town's website at www.yarrnouth.ma.us under Health Department, Downloadable Farms. FROZEN DFSSERTS: Prozeu desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Deparhnent. Failure to do so will result in the suspension or revocarion of your Frozen Dessert PemuC until the above terms have been met (}UTSIDE CAFES. Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOQR COOHING: Outdoor cooking,prepazatian,or dispIay of any food product by a retail or food service esiablishment is prohibited. NOT.ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILI`l'Y TO RGTtJRN THE COMPLBTED RENEWAL APPLICATI4N{�)AIQD REQUIRED FEE(S}BY DECEMBER 1 S, 2014. ALL RENOVATIONS TO ANY FOOD FSTABI,ISHMENT, Md'1'EL OR POdL (i.e., PAINTING, NEW EQUIPMENT,ETC.},MUST BE REPOItTED Td AI��D APPR4 VED BY THE BOt1It.D OF HEALTH PR1QR ' TO COMMENCEMENT. RENOVATIONS MAY RE IRE A SITE PLAN, ` , ` ' � �- I7A1'E: L� � 1 1 �� SIGNATURE;' � PRINT NAME& TITLE: � }.� . Rev. 11f03R4 �-� � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 1 Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dda Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: G.r— l A1 � Address: City/State/Zip: U Phone#: ��6�Cj D 3 �D D Are you employer?Che the appropriate bos: Business Type(required): 1. I am a employer with employees(full and/ 5. ❑ Retail or part-time).* � 6. ❑ RestaurantBaz/Earing Establishment — - - - - - -- _ 2. I am a sole propnetor or partnership an3have no �, � Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We aze a corporarion and its ofFicers have exercised 9. ❑ Entertainment their right of exemption per a 152, §1(4), and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, I 1.0 Heaith Care, , with no employees. [No workers' comp. insurance req.] 12.�ther � (� � I - (yb L� 'Any applicant that checks box#I must aLso fill out the section below showing their workecs'compensation policy in£ormation. •'If the corporate officeis have exempted themselves,but the cotporabon has otha employees,a workers'compensation policy is required and such en organization should check box#1. . I am an employer that isproviding workers'compensation insurance jor my emp[oyees. Befow is thepolicy infosmation. Insurance Company Name: �(�� ,Q y o �LS Insurer's Address: City/State/Zip: V � Policy#or Self-ins. Lic. # �CG I�i �.�I Expiration Date: �-� - � � Attach a copy of the workers' compensa 'hon policy declaration page(showing the policy nnmber and ezpiration date). _ Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalfies of a - - - -- - - - fine up to $1,500.00 and/or one-yeaz imprisonmenf,as we�l as civil pena�lhes in trie�orm of a ST`OP WOtZKaRI�ER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby certi under the pains an ena ' ofperjury that the information provided a6ove is bue and correct �� Si ature: � Date: �- O- Phone#: �mi� C� 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/Towu Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia .