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Home My WebLink AboutApplication and WC . ^ Nrc a TOWN OF YARMOUTH BOARD OF HEALTH R� � ° � �� APPLICATION FOR LICEN � � ��• �� UtG ��I 5 ZO14 `� * Please complete form and attach a11 nec�ary �n#s y c mber 15 2014. Fai lure to do so wi l l resu lt in t he r yo`ur app lica tion ac L 7 H D E P T. ESTABLISHMENT NAME• a�A.oa ��'Af,�A/+7 ° TAX ID•� LOCATION ADDRESS: ac� D,�r�i s R�AA SrwTir/r�R�no��,�n'A oa66 y� TEL#��&39$. yo3a MAILING ADDRESS: �v /✓)o� 3*� .Sa�rrN yj�,p,�leri�////h' oa��sL o �a 3 E-MAILADDRESS: �!� OWNER NAME:L/nu//�h� �af/G E H �": �A•f% /%ll.�i✓/C ?Rv.SF CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:�L�i/7�1 A GkeE.�/..S�Tii - ��' TEL.#:59� 3�-�'�/P�3 MAILING ADDRESS:0?5 frlic,y�t��'� PAfs!�'�'A�tT/ni1�.Y'/�7_ /�7��6 Z� 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 minimuxn of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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 prov�de new copies and maintain a file at your place of business. 1. 2• 3. 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS: e-�'� � ��u' � /V4�!� All food service establishxnents 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 Heatth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2• _ �RSIIIV I�f�rIA32GE: __ . - _-- - -- _ . __ _ - _-_ Each food establishment must have at least one Person In Chazge (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 �le at your establishment. i. l�✓,«.�� f� G�cc.�E S z. ��R�sr..v�- �- G,�,c�� 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. �. w� , ,� � G��,� T z. C,�,�.�r,�.� �. G�,� 3. /�E��,r SG/Moe/R 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —INN $55 CAMP $55 SWIMMING POOL$l l0ea. LODGE $55 TRA[LERPARK �$105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT 0-t00SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 �/ � � >]00 SEAT5 $200 COMMON VIC. $60 WHOLESALE $SO — — —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $IS AMOiJNT DUE _ $ 30 .00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•*• - . ADMINISTRATIdiV Under Chapter 152, Sectian 25C,Subsection 6,the Town af Yacmouth is now required to hold issuance or renewal af any license or'.permit to operate a business if a person or company does not have a Certificate of Worker's Cam�rensatiatt Insurance. THE ATTACAED STATE WORKF:R'5 CQMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR f f!f C�RT. OF INSLTRANCE ATTACHED ",.-_""� OR �----T WCJRKER'S COMP. AFF`IllAVIT SIGNED AND ATTACH�D � Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS ANA OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limiiatioivs of Motel or Hotel use,Txansient accupancy shall be limited to the temporary and short term occupancy,ordinarily and custnmarily assoeiated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a prJncipal place af residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not moze than thirty(30)days,and an aggregate a£not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be cansidered transzent. 4ccupaney that is sabject ta the collectian of Room Occupancy Excise,as defined in M.G:L. c. 64G or 830 CMR 64G, as amended,shall generally be oonsidered Transiant. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for ihe season rnust be izaspected by the Health Department prior to opening. ConYact the Health Department to schedule the inspection three(3) days prinr to vpening. PLEASE NOTE: Feaple are NOT allowed ta sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested 1'`ar pseudomouas,total coli£orm and standard plate count by a State certified Iab, and submitted to the Health Departrnent three (3) days ptior to opening, and quarterly thereafter. P�OL GLOSING; Every=ouidoor in ground swimming paoi must be draii7ed or covered within seven{7)days of closing. — FOOD SEI2VICE SEASONAL FOOD SERVICE OPENING: ' All food service establishments must be inspected by the I Iealth Depaztment prior to opening. Please contact the Fiealth Deparfinent to schedule the inspection three (3)days prior to opening. CATERING POLICX: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health T7epartment by filing the reqmred Temparary Foad Service Applicatian f'orm 72 haurs prior to the catered event. These forms can be abtained at the Health I7epartment,oz fram the Town's website at www,yarmoukh.ma.us under Health Department, Downloadable Farrns. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. FaiIure to do sa will result 'rn the suspension or revocation of your Frozen Dessert Permit until the abave terms have been met. OUTSIDE CAFES: Qutside cafes(i.e3_outdoor seatin�with waiter/waitress service),must have pzior approval from the Board of Health. __ _ QUTllOOR COOHING: Outdaor cooking,prepazation,ot display of any food product by a retail or faod service establishment is prohibited. NOTICE; Permits run annually from 7anuary 1 ta December 31. I'1'IS YOUR I2E31'ONSIBILI'I'Y 7`O RETURN TI-IE COMPLETED RENEWAL APPLICATION(S)ANi}RGQUIREI?FEE{S}BY DECEMBER 15, 2014. ALL RENOVATIONS TO AIvTY FOOD ESTlt.BLISHiVIENT, MOTEL OR POOL (i.e., PAINTING, NEW �QUIPMENT,ETC,}, MUST BE REPORTED TO AND APPROVED BY TI-IE BC?f1F2D OF HEAI.TH PRIOR TO COMMENCEMENT. RENOVATIQNS MAY REQUIRE A SITE PLAN. �AT�.1��r��/.�'l�szGrr�Tu�:,�'i��-ll', � �-.��1 PRINT NAME & TITLE: ,�G��.t�%. G�i°� J,e --�,�"',��,y,ep .�yp�E 2eY. �irosna /�•�TSudie'�sT . � The Commonwea[th ofMassachusetts Department of Industrial Accidents Office oflnvestigalions I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aunlicant Information �� Please Print Legiblv Business/Organization Name: �— Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranUBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � p}�ce 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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.Q Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other •Any applicaztt t6at checks box#1 must also fill out the section below showing the'u workers'compensation policy informffiion. '•If the coxporete officers have exemp[ed themselves,but the cocporation has other employees,a workers'compensation policy is required and such an organizalion should check box#I. I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the policy informalion. Insurance Company Name: Insurer's Address: City/State/Zip: Policy# or Self-ins. Lic.� — ——� — -- -- �x�siratioTrI?ate.— - ---- — — Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiraHon date). Failure to secure coverage as required under Sec6on 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 Investigations of the DIA for insurance covemge verification. I do hereby cen�,under the pains and pena[Kes of perjury that the information provided above is true and correct. Signature: Date: Phone#: Officia[use only. Do not write in this area,to be comp[eted 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 '�