HomeMy WebLinkAboutApplication and WC (New Owner) r------� - .
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� . TOWNOFYARMOUTHBOARD ,�`py'��'�."; � �, MN.� ; 67�15
' APPLICATION FOR LICENSE/PE �■[ '�� P
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'Please complete form and attach all necessary documents by December I S 2 14. �-;�_;�_�ru �FpT
Failure to do so will resuk in the return of your application pac et. �-
I
ESTABLISFIMENT NAME: � ' �
LOCATIONADDRESS: I 'v, S TEL.#: - � �- 27
MAII.ING ADDRESS:
E-MAII,ADDRESS: tAvS.COM
��. OWNERNAME: lo t� W �
CORPORATION NAME(IF APPLICABLE): ��I�s v�C .
MANAGER'SNAME: � et�I- � TEL# S34 �4�J-� -1
MAILING ADDRESS: �S ��
POOL CERTIF'ICATIONS:
�� T6e pool supervisor must be cerlified ae a Pool Operatoq as required by State law. Please listthe desigoated
'��. Pool Operator(s)and attach a copy of the certification to flils foan. .
I 1. 2.
Pool operators must list a minimwn of two emplo ees currenfly certified in basic water safery,standard Fust Aid
and Community Cardiopultnonary ResUscitation�CPR),Laving one certified employce on premises at ell times.
Please list ihe employees below andattach copies oftheir certifications to flus form.The Health DeparEment will
not use past years'recorda. You must prov�de new mpies and maintain a fite at your place ot bnsiueas.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS-CERTlFICATIONS: �
All food service es[ablishments are required to have at least one full-time employee who is certified as a Food
Protection Manager,as defined ia the State Sanitary Code for Food Service Fstablishments, 105 CMR 590.000.
�- Please attach copies of cerlificaflon to this application. The Health Department w�l not nse past years'records.
You mnst provide new copies and mainkain a£le at your establishment
1. �oHN �62cir/ 2. L.Sif c`��CJ2iCCaE
���raa��c-L
PERSON IN CHARGE:
�� Each food esfablishmert must have at least one Person In Charge(PIC)on site d�su�g hours of operation.
..,, 1. seoT7' �j�,=./aG 2. .
' ALLERGEN CERTIFICATIONS:
i All food service establishmeats ere requ'ved to have at least oae full-time employee who has Allergen certification,
'�� as defined in the State Senitary_Code for Food Service Establishments,105 CMIt 590.009(G)(3)(a). Please attach
'. copies of certification to tivs application. The Health Department wiR not uae past yeara'.recorda. You must
provide new copiea aad maintain a file at yoar establishment. �
' I. Jc�e!-�� {'�.�.rr�a/cl 2. �S '�--� ' �
�
HEIl�YL,ICH CERTIFICATIONS:
All food service establisLments with 25 seats or more must have at least one employee trained in the Heimlich
Maueuver on the pcemises at all times. Please list your emngloyees 4sined in anti-choking ptocedures below and
attach copies of employee certifications to tlus form. The Health Deparhnent will not use past years'records.
You must provide new copies and maintain a file at yoar place ot business.
1. 2•
3. 4.
RESTAi7RANT SEATING: TOTAL# ��
OFFICE USE ONLY �
LODGING:
LICENSE REQUIl2P.D PEE PERMIT# LICENSS REQUQLED FEE PERMIT# WCENSE REQUIRED FEE PERMIT N
B&B $55 CABIN $55 MO'fEL S110
—INN S55 CAMP $55 SWIIvA�llNGPOOLS�IOm.
=1.ODGE S55 =IRAILERPARK 5105 _WHIl2LPOOL SllOea
FOOD SERVICE:
[CENSERE UIl2ED FHE P,�.RhA_Tjl LICEN58REQU[RED R6E PERMITH CICENSERFAUIRED FEE PP.RMiT#
�i o-�oossngrs aiu �0(p COMINEN"CAL $?5 NON-PROFIf 530
»aosEArs sam `'�J �COMMONVIG S60 A�FI .��R� =RFSN.KITC7�N580
RETAII.SERV[CE: �
LICENSEREQUIRED FEE PERMITR GCENSEREQUIRED PE8 P8R0.UTq LICENSEREQUIRGD F6E PERM[Tii
<50sq R $50 >25000 ft. 5285 VENDING-POOD §25
=¢S,OOOsq.ft $150 �'RdZEN�ESSERT $40 _TOBACCO S1I0
NAME CHANGE: St5 AMOIINT DUE _ $ `� `��j
SG ••••�PLEASETURNOVF.RANDCOMPLETEOTRERSIDEOFFORM•"**" �� �����D
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Under Chapber 1 S2,SecLion 25C,Subsection 6,the Towra of Yazmouth is nowrequired to hold issuance or renewal
of any license or germit to opaiake a bu.ainess if a person ar eompzuy does aot have a Carcificate of Worker's
Compensation Insurance. THE ATTACFLED STATE WORKER'6 COMP&NSA7'ION INST,JI2ANCE
� � ARFIBAVST MUST BE CQMPI.ETED AND$IGNED,flIt
CERT.6F 2NSU12RNCB AT TACIlED,
i ox
wa�x�s catv�.nr��m�vrr st��n ntvn nrrac�v
� Town af Yermouth 4�es�d liens mvst be paid prior to renewat or Sssuauce af your pezmits. PLEASE CHECK .
� APPROPRIATELY IF PAID: �
YES � NO
MIO'.CEI,S AlVD OTHER LODGING ESTABL7SI�N'T'S
TRANSIENTOCC[tPANCY: ForpwposesofthelimitatiansofMotelarHote]use,T�arvsieatoccugaacyshallbe
limited to tlr,e temporaey and short term oocupancy,ordintrrily and cuskomar�ily associated with motel and kotel use.
Transieat occupants must ha.ve a.nd be ahle to demonsUate that they maintain a priacipa! place of residence
elsewb.ere.Ttausiant occupancy sLall geuerally�fer to continunus occupancy ofnot mnre flzan tivriy(30)days,and
ansggA�egateofnoYmorethannmety(90)dayswifhinanysix(b}monthperiod. Useofaguestunitesaresidesceor
dweUing uuit shall not be cansidrred tcansient. Occupaney tl�at is subject to the collaction of Rpom Ueeupancy
Excise,as defiaed in M.G.L.c.64G or 830 CMR S4G,as amended,shaFt generally be considzreti Transient.
PQOLS
P40L QPEIYIIYG:AI!swimmin�,vrading and whirlpools whichbave beenclosed forthe sea.,onmusk be ins�ected
by the HealtL Depazhnent prior to o ning. Gantact the Heaithj�p artment to echedule the rospection tLree(3)
days prior to opening, LEAS �T :People are NOT allowed to sit in ihe pool area unfit the pool has been
i�aspected and opened �
POOL WATER TESTING: The watermust be tested forpseudamonas,total catifoim and standard plate count
by a State eertified lab,and submitted w the Health Depaztment th[ee(3)days priar to openin{,�, �d quarterly
thet�eafter.
POOL CI,CISING:Every autdoor in ground swimming pool mustbe dtaiued or covcred within seven(�)days of
closing.
FOQD SERYICE
9EA80NAI,FOOD SERVICE OPENING:
All food service astab]isLments must be inspected by the Health Deputmreat prior to opening. Please contact the
Health Deparnnent to sohedule the inspecrion three(3)days prior to apemng.
CATETtING POLICX: �
Anyone wha cate.ts within the Towa of Yarmouth must notiPy the Yamiouth I-Iealth Depaztwent by filing the
xeqmred Tetnporary Food Service ApplicaT3on form T2 hout�s prior Ya the catered eveut. 'I�ese fottos can be
abtained at the Health I?epartment,or&pm tha Town's website at www.varmouth.maus under Health D�.parttt��ent,
Downtoadabie Forms.
1+"RQZEN DESSERTS:
Frozen desserts must be tested by a State cettified lab priot to opening and monthiy thereafter,with san�ple resuits
submi.tted to the Health Department. FaiLse ta do so ovill result in�the suspension pr zevocafion of your Frozen
Dessert Permit unfil the above tenus I�ave been met.
OT3TSlDE CAFL`�S:
Clutside cafes(i.e.,outdoor seating with waiterfwaitreys yqvice),must have ptior approval&omihe$oard ofFIeslth.
OUT!)OOR COOI{�I6:
Outdoor coaking,prepatation,or dieplay of any foodproduct by a retaii or food service ostablishmeptis prphi6ited.
NOTICE:Permits run amualty fiom 7anuary 1 w December 31. IT IS YQUR RESPONSIBIIIT"S'TO 1�1'IJRN
THE COMPLETED RENEWAL APPLICATION(S)ANU REQ(IAtED FEE(S)BY T7ECENIDER 15,2-014.
ALL RENpVATCpNS TO ANY FOOD ESTP.HLISHMENI', MOTEL OR POOL {i.e., PALNTIlVG, NBW
EQUIPMENT,E'I'C J,MUST BE REPQILTED TO AND APPROVED BY THF,'BOARD pP HEALTFi pgIp�
TO COMMkNCEMENT. RENOVATIONS MAY RE ,A S'TjPLAN.
DATE:___���__$IGNATIJRE: _
PI2IN'1'NAME�"C'ITI,E: d
nev.u�n7na
i
• ", � The Commonwealth ofMassachusetts
Depariment oflndustrdalAccidents
Office oflnvestig¢tions -
I Congress Street,Suite 100 '
Boston,MA 02II4-2017
www.mass.gov/dia
Workers' Compensation Insnrance Affidavit: General Businesses
Apalicant Information Please Print Leeiblv
Business/Organization Name:�I�(��� 1 v+c� o�bw I� '��G'''�a/� `�^?""w+lA-t�s
' Address:_ I �q-7 t`Ylw�-, S-4 • S`:j�.__.,-._.,�1f-L�_ .)
City/State/Zip: S. /c`,.--y,,��,z�-Il-, Phone#:
Ar�e y an employer?Check the appropriate boz: Basiness Type(reqnired):
I 1.L� I am a employer with��employees(full andl 5. ❑Retail
I or part-time).* 6. �Restaurant/Baz/Eating Establishment
� 2.❑ I am a sole proprietor or parmeislup and have no 7. � Office and/or Sales(incl.real estate,suto,etc.)
' employees working for me in any capacity.
[No workers' comp.insurance required] S. ❑Non-profit
I3.❑ We are a corporazion and its officers have exercised 9. ❑ Entertainment
their right of exemp6on per c. ]52, §1(4),and we have 7 0.0 Manufactwing
no employees. [No workers' comp.inswance required]*
4.❑ We aze a non-pmfit organization,staffed by volunteers, 11.❑Heakh Care
with no employees. [No workers' comp.insurance req.] 12.❑Other
, 'Any applicent that checic�box#I must aLso fill out the swtion below showiag their workces'compensation policy mfocmeti�.
*'If the co�porate officers heve e�cempted themselves,but the co:pom6on has oih�employces,a workeis'compensatioa policy is roqu'ved and such en
_ oiganir�tion should ck�eck box#I.
I am an employer thaf as providing workers'compensation insurance for my emp[oyees Below u the policy infonnation
Insurance Company Name:�,�. �i� �tc�.�s � r� �vt S �n.
G� ' 3�5
Insurer's Aadress: � �ir'c�r„- �osf.e�/ I�Yc�isav. ��.c
c�ty�srat�zip: YYI�m-;s+v�w,-� NJ c57�1��2
�-ta �� �si ► b� - � �� ..�`��.
Policy#or Self-ins.Lic.# Expiration Date:
i AttacL a copy of the cvorkers' compensakon policy declara6on page(sLowing the policy nnmber an ezp➢ ation date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminat penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as weFl as civil penalties in the form of a STOP WORK ORDER and a&ne
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Of6ce of
Investiga#ions of the DIA for insurauce coverage verification.
II do hereby certi ,u r the 'rrs and penalties ofperjury that the information provided above is bue and corrux.
i e• Date:
ho e#:
Official use on1y. Do not write in thts area,to be completed by city or town officiaL
Ciiy or Town: Permit/License#
Issuing Anthority(circle one):
1.Board of Health 2.Building Department 3. City/1'own Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
� ContaM Person: Phone#:
Iwww.mess.gm/dia