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Home My WebLink AboutApplication and WC y ld TOWN OF YARMOUTH BO�R1�Q� L'�GcL�MCDD � �'�S�'A� 5 ,�C-t �ivt2 �� APPLICATION FOR LIC�ENSE/PEx23Vt ,'.2 '�: �� e�zg,4 � � �"°` * Please complete form and attach a11 �ecessary�doc ents by Decem er IS O14. Failure to do so will result in the return of yo app}�Ec�y ��2�� ESTABLISHMENT NAME: � AX ID• - LOCATION ADDRESS;_ o �I � TEL.#: / �f 9 Z�J MAILING ADDRESS: P a, ��x Ft�t �' � [7cxi rti,�' S M�4- D 7Jo��[� E-MAILADDRESS:'-' �'o�17`I fF � OWNER NAME: e-n,., � ��Q �/1 CORPORATION NAME F PLIC ): MANAGER'SNAME:�I.{�C.-�,_ _ TEL. �Q TA 1 - `lqZ'� MAILING ADDRESS: ��I �( 1 . �1�. . B.o s� 1P 01.� 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 cop�r 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 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 provide new copies and maintain a file at your place of business. 1. Z• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: � °� C�• � �� All food service establishments are required to have at least one ful -time employee who is certi ed as a Food 0� 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. Yo must provide n w copies and amtain a file at your stablishment. �. �� 3� _ -��5��F: ---- _ . _--- - -- - -- ----- - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. /`_I L.�_ �� ALLERGEN CERTIFICATIONS: `J �v� ,2�.�.e-��-.-. All food service establishments aze required to have at least one fixll-time employee who has Allergen ce ification, 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 Deparhnent will not use past years' records. You must pro de n w copies and�in a fi t your establishment. 2. vb � 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. Z• 3, 4. RESTAi.JRANT SEATING: TOTAL#�I �- f�l.�I-^--� J 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 $55 SWIMMING POOL$ll0ea � LODGE $55 1RAILERPARK $105 _WHIRLPOOL $IlOea. '. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE�g�i II 0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 � — — —RESID.KITCHEN $80 RETAIL SERV[CE: �� 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 $110 rtwmE CHnNCE: 8�5 AMOUNT DUE _ $ 3G-G O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � f N ADMINISi'RATION Under Chapter 152, Section 25C, Subsection 6,the Town af Yarmoufh is now required to hold issuance or renewal af any license ar permit ta operate a business if a person or cmnpany does not have a Certificate of Worker's Compensation Insurance. THE AT'TACHED STATE WOI2K�R'S Ct?MPENSATION INSURANCE AFF'IDAVIT MUST BE C'OMPLETPI3 AND SIGNED, OR CERT. OF INSURANCE ATTACHBD OR —� W4RKER'S COMP. AFFIDAVIT SIGNED AND A'TTACHED� Town of Yarmouth taates and liens must be paid prior to renewal or issuance of your permiEs. PLEASE CHECIC APPRQPKIATELY IF PAID: YE5� NO M4TELS AND OTFIER I.4DGIlYG ESTABLISHMENTS ' TRANSIENT OCCUPANCY: For purposas of the limitations ofMotel ar Hotel use,Transient occupancy shall be limited to the femparary and short term accupancy,ardinarily and custoxnarily associated with matei and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirry(30)days,and an aggregate of not more than ninety(94}days within any six{6}month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subjecY to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shaIl generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed For the season rnust be inspected by the Health Department prior to apening. Contact the Health Department ta sckedule the inspection three{3) days prior to opening. PI,EASE NOTE: People aze NOT allowed to sit in the poal area until the pool has been inspected and opened. POOL WATER T'ESTING: The water must be tested for pseudomonas,total wliforna and standard pTate count bp a State certified iab, and submiYted to the Health Departciient three {3) days prior to opening, and quarterly thereafter. POOL CL03IING: Every outdoor in ground swimn�ing pool must be drained or covered within seven(7)days of closing. FOOD SEI2VICE SEASONAL F0t3D SERVICE OPENING: All food serv9ce establishments must be inspected by the Health Department prior to opening. Please contact the Heaith DeparUnent to schedule the inspection three (3) days prior to opening. CATERING POLICX: Anyana who caters within the Tawn of Yarmouth rnust notify the Yarmouth Health DeparEment by filing the requ�red Temporary Food Service ApplScation form 72 hours prior to the catered event. These farms can be obtained at the Hea3th L}eparTment,ar fram the Tawn's website at www.yarmouth.ma;us under Health I}epartment, Downloadable Forms. FROZEN DESSERTS: Frozan desserts must be tested by a Stata certified lab prior to opening and monthly thereaftet,with sample resuIts submztted to the I-Iealth Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been rnet. QUTSIDE CAFES: C7utside cafes(i.e.,outdoor seating with waiterlwaitress service},must have prior approval from the Boazd of Haalth. _ --__----_ ___ - _ _ _ _ _ _ - - __ _ --- OUTDOORC04KING: _____ _ _ Outdoor cooking,prepazation,ar display of any food product by a retail or faod service establishment is prohibited. 1�OTICE:Pernuis run annually fram January 1 to December 31. IT IS YOLTR RESPONSISILITY TQ RETI.TRN THE COMPLETED RENF,WAL APPLICATION(S)AND REQUIRED FBE(S) BY DECEMBER 15, 2014. ALL RENOVATIONS TQ ANY FOOD �STABLISHMEIVT, MOTEL OR PdOL {i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE 12EPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY I2EQUII2E A SIT�PLAN. L1ATE: t�I.,� I �-i SCGNAT`tTRE: � PR1NT NAME& TITLE cx,. I �av. u/osna y � The Commonwea[th ofMassachusetts Department oflndustrialAccidents Ojfice of Investigations ' l Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Nazne: �)�Y�.� � a � 1�[� � Address: Ciry/State/Zip: Phone#: Are you an employer? Check the appropriate boa: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant7Baz/Eating Establishment 2.❑ I am a sole proprietor or parmership 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 are a corporation and its 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]* —&�] We aze a non-profit organizarion, staffed by volunteers, 11.� Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicmmt that checks box#1 must also fill out the section below showing the'v workers'compensa[ion policy information. *•If The coiporete officers have exempted themselves,but the corporatioa has other employees,a workers'compensatioa policy is requ'ved and such an olganizalion should check box#1. I am an emp[oyer that is prnviding workers'compensation insurance for my employees. Below is the po[icy information. Insurance Company Name: Insurer's Address: City/State/Zip: .__. _�6�ICj'�-GC-.�P.�II15�f,1��r_ ___"____.—'_.__--_"_ __—__._—�'ef�klYi�'16T1'Dfi�B: __ _"—.._._ ... ._—_ Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration 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 Inves6gations of the DIA for insurance coverage verification. I do hereby cenify,under the pains and penaUies ofperjury that the information provided above is true and correct. Si ahve: V� vV1.oCS.�, fCA�S� �^,�y� Date: IZI I X f I J� Pho�e#: �� 4S'c?b Z'7 �-15 Official use on[y. 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