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Home My WebLink AboutApplication and WC ' . CffS 6F lt�c.T-�36 �'� �� -_� �D a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE �'I 2 �hNi1 I�-LQ15 * Please complete form and attach all necess do `" ;[3 �T. Failure to do so will result in the return of your app icatio e . ESTABLISHMENT NAME: TA D• - $ LOCATIONADDRESS: Iq �L �#: I,�s+ �qcca.rmoi�th f711rT��.#:,�-J75'- US� MAILINGADDRESS: ( �S�/ECf �PPr�,nk, (V�a 8'1�'ll E-MAILADDRESS:�pGi,iO..r� �a,ol . C.orv� OWNER NAME: CORPORATION NAME APPLICABLE): (i �1 ��V 6 y s-�3y 9 MANAGER'S NAME: O a'1 f tA S TEL.#: MAILING ADDRESS: 1'Sq -f ry1 5 f�l�� A f� TI I 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 minunum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at a116mes. 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�le 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 will not use past years'records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON IN CHARGE: 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 establishxnents 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 Sle 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 — $55 —SWIMMINGPOOL$IlOea _LODGE $55 =TRAILERPARK $105 WHIRLPOOL $(l0ea. FOOD SERVICE• LICENSE RE�UIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEA S $125 �15�/('�+ CON7'[NENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 � —WHOLESALE $80 RETAIL SERVICE: —RESID.KI'I'CHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 <ZS,OOOsq.ft. $150 - =FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ /,q5_pp *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRA,TIUN Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yannouth is now required to hold issuanae or renewal of any license or permit to operate a basiness if a person or company does not have a Certificate of Worker's Compensation Insurance. THE AT'I'ACHED STATE WOTtKER'S CCfMPENSATI4N INSURANCE AFFTDAVIT MUST BE COMPLETED AND SIGNEU, CMR CERT. QF INSURANCE A.TTACHED V OR WORKER'S COMP. AFFILIAVIT SIGNED AND ATTACHED 1'orvn of Yarmouth taaces and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATEIrY IF PAID: YE5 N4 _ MOTELS AND OTHER LODGING ESTABIa[SHMENTS TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hotel use,Transient occupancy shall be limited ta the temporary and short term occupanoy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a grincipal place af residence elsewhere.Transient accupancy shall generally refer to 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. Use nf a�,�uest unit as a residence or dwelling unit shall nat be cansidered transient. Occupancy that zs subject ta the collection af Room 4ecupancy Excise,as defined in NI.G.L. c. 64G or 830 CMR 64G, as amended,sha11 generally be considered Transient. PQt7LS PQOL OPENING:AIl sw'smming,cvading and whirlpools which have been ciased for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days priar fa opeaing. FLEASE NOTE: People are NOT allowed ta sit in the poal azea until the paol has been inspected and opened. POdL WATER TESTING: The water must be tested for pseudomanas,total coliforrn and standard plate caunt by a State certified lab, and submitted to the HeaIth Department three (3} days prior to opening, and quarterly Ithereafter. P(}OL CLOSING:Every outdoor in ground swimming paal must be drained ar covered within seven{7)days of olosing. , FOOD SF.RVIC� SEASONAL FOOD SERVICE OPEIVING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health I}epartment to schedule the inspection three(3)days prior to opening. . CATERIIVG POLICY: Anyone who caters within the Town nf Yazmauth rnust notify the Yannouth Aealth Department by filing the requ�red Temporary Foad Service Applicatian form 72 hours priar to the cater�d event. These forms can be obtained at the Health 17eparhnent,or from the Town's website at www.}�urnouth.ma.us under Hea1tU Deparhnent, Downloadable Fanns. FRUZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and montlily thereafter,with sample results submitted to the Health Department. Faiture to do so will result in the suspension or revacation of yaur Frozen I7essert Permit untii the above terms have been met. OUTSII7E CATES: Outside oafes(i.e.,outdoor seating with waater/waitress service),must have prior approval from the Boazd of Health. � CIUTDOOR COQHING. Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Petmits run annually from January 1 to December 31. IT IS YO[TR RESPONSIBILI'T'Y 1'O R.ETtlRN THE CQMPLETED RENEWAL APPLICATION(S}AND REQUIRED FEE{S}BY DBCEMBER 15,2014. I ALL RENOVATIONS T4 ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., P�.IIV'TTNG, NEW EQUIPMENT, ETC.},MUST BE REPC}RTED TQ AND APPR{7VED BY THE BOARD OF HEALTH PRIOR TQ COMMENCEMENT. RENOVATIONS MAY REQUT A SI E PLAN. DATE: � " f�� I,5 SIGNATIJRE: �� PRiNT NAME& TITLE: � -� D Kev. ii1Q3l14 �� The Commonwealth ofMassachusetts Department oflndustrialAccidents O�ce oflnvestigations ' 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apnlicant Information Please Print Le¢iblv Business/Organization Name: Address: City/Staxe/Zip: Phone#: Are yon an employer? Check the appropriate box: Business Type(reqnired): 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, � Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. (No workers' comp. insurance required] $• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp.insurance required]* I 1.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other `Any applicant[hat checks box#1 must also fill ow.the secrion below showing[heir workers'compensation policy infoimatioa. '•If the co:porate officecs have exempted themselves,ba[the wxporation has other employees,a worlcecs'compensatioa policy is:equired�d such m organizalion should Check box#I. I am an employer that isproviding workers'compensation insurance for my employees. Be[ow is the policy informatioa Insurance Company Name: Insurer's Address: City/5tate/zip: ��l� �C �X I/�l� �,�T �LF /N S' Policy#or Self-ins.Lic.# Fxpiration Date: Attach a copy of the workers' compensation policy declaration page(shawing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$I,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP VJORK ORDER 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 Invesriga6ons of the DIA for insurance coverage verifica6on. I do hereby cerh;/,under the pains and penalties of perjury that the information provided above u irue and corred S�nature• �/ �r/t�(��'�—�7 Date � /��lT— Phone#: / Ojficdal use only. Do not write in thu area,to be completed by city or town officiaL City or Town: Permit/License# Lssuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Towa Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#• . www.msss.gov/dia