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Home My WebLink AboutApplication and WC ( 1 � TOWN OF YARMOUTH BOARD OF HEALTH ��' � o �� APPLICATION FOR LICEAIS�F�VII -_ 1 Utl; Z 9 `CU 14 " * Please complete form and attach all n�cessar�c�o� ein�s ec mber IS 2014. , Failure to do so will result in thu xetur�isfyflue.�p licahon ac PT• ' ESTABLISHMENTNAME: lv1 � � b n � T ID: LOCATION ADDRESS: 5 I , �0'►cx.�- TEL.#: d - 7� - MAILINGADDRESS: ,�/ei i�o�� r28 !�(�. 11 v�rti � (/"10. Ur�fo'�� E-MAIL ADDRESS: OWNERNAME: At2"i"�I-c� R nl. �.,� E CORPORATION NAME (IF APPLICABLE):�,n S��P SCoo� LC.0 ', MANAGER'SNAME:'�G.4�'� 4�Pa`l�"- I=r� �� TEL.#: hb8 9+1�-6-I Rj MAILINGADDRESS:��I<{ � �� ,'�7-R' 1.t7� vrno7..`4�, Mti' �,�(0�23 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 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 Ilealth 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 will not use past years'records. You must provide new copies and maintain a Sle at your establishment. . 1. W � l ( �w ��de l{'1 ��ii'iG ��G�. � �f'lll't� � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. , _ _ _ _ _ - - - - _ , - -- - ------ - 1. _ Z• ALLERGEN CERTIFICATIONS: � All food service establishments are required to haue at least one full-time employee who has Allergen certification, 'i 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 I� provide new copies and maintain a file at your establishment. I 1. Z• ' HEIMLICH CERTIFICATIONS: i All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich i 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. I You must provide new copies and maintain a file at your place of business. ', 1. 2. 3. 4. � � RESTALJRANT SEATING: TOTAL # i OFFICE USE ONLY GODGING: 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$110ea '��.. LODGE $55 —TRAILERPARK $(OS WHIRLPOOL $110ea. � FOOD SERVICE: '. L,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# l 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 >I00 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,OOOsq.ft. $150 � �FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ I ZcS,O O '�. **•**PLEASE TURN�OVER AND COMPLETE OTHER SIDE OF FORM•"*** �G �'^ � �S O�/ ��, � �e ��r�s ,u� � �G� � ��--/a-9f�� I ADMINISTRATIQN , [Jnder Chapter 152,Section 25C,Subsection 6,the Town of Xannauth is now required to hold issuance or renewal � of any-license or p8rnait to oparate a business if a person or company does not have a Certificate of Worker's j Campensation Insurance. TIiE ATTACHED STATE W412.KER'S Ct}MPENSATION INSIIitA1VCE I AFFIDAVIT MUST BE COMPLETED AND SICNED,(?R i 1 CERT. OF 1NSURANCE A TTACHED � OR ^ / WORKER'S COMP. AFFIDAVIT SIGNED AND A'ITACHED �l Town of Yarr�zouth taxes and liens rnust be paid prior to renewal or issuance of your permits. NLEASE CHECK APPIZOFRIATELY IF PAID: YES NQ MOTELS ANA OTHER LODGING ESTABLISHMENTS � TRAIVSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinarily and customarily assoaiated with motel and hotel use. Transient occupants must have and be able to dernonstrate that they maintain a principal place of residence elsewhere.Transient accupancy shall generally refer to continuous occupancy af noY more than thirty(30)days,and � an aggregate of not more than ninety(90)days within any six(6)mpnth period. Use af a�uest unit as a residence or dwelling unit shall not be cansidered trarisient. Occupancy that is sabject to the collection of Room 4ccupancy Excise,as defined in M.G.L. c. 64G or 834 CMI2 64G, as amended,shall generally be considered Transient. � PQpLS P4dL OPENING:Atl swimming,wading and whirlpools which have been closed f'or the season must be inspected by the Health Department prior to opening. Contact khe Health Department to schedule the inspection three(3) days prior to opening. PLEASE NdTE: Peaple are NOT allotived to sit in The pooi area until the poot has been inspected and apaned. POdL WATLR TESTING: The watez must be tested for pseudnmonas,total coliform and standard plate count tlie eaftexe certified lab, and submitked to the Health Deparhnent three (3) days prior to opening, and quarterly POOL CLOSING: Every outdoor in ground swimming pool must be drained ar cavered within seven{7)days of � closing. . FOOD SERV[CE SEASONAL FOOD SERVICE OPENING: � All food service estabtishments must be inspected by the Health Department prior ta opening. Please contact the Health Depariment to scheciu(e the inspection three(3) days prior to opening. � CATERING PQLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Depaztment by filing the required Temporary Faod Service Appiication farm 72 haurs priar to the catered event. These forms can be abtained at the Health Department,or from the Town's website at www.yarrnouth.ma.us under Haalth Deparhnent, Downioadable Forms. �ROZEN DESSERTS: Frozen desserks must be tested by a State certified 1ab prior to opening and monthly ihereafter,with sample results submitted to the Health Department. Failure to do sp wilt result in the suspension or revocation of your Frozen Dessert Permit untii the above terms have been met. t3U1"SIDE CA�'ES: (7utside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. ; OUZ'DOOR COOHIIVG: � Outdoor cooking,preparation,or dispIay of any food product by a re#ail or food service establishment is prohibited. ( �-- ---.--_. —.__—__ _. _ _ _ _--- -- . i . __ _---. _ __ _ NOTICE: Permits run annually from 7anuary 1 to December 31. IT I5 YOUR RESPONSIBILI`TY TO RETtTRN � THE COMPLETED RENEWAI,APPLICATIQN(S}ANI}ItEQI3IRED FEE(S}BY DECEMBER I5, 2414. � ALL RENOVATION3 TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'T'ING, NEW i EQUIPMEN'I',ET"C.),MITST BE 12EPORTEI}T{}AND APPROVED BY THE Bt?ARD OF HEALTH PRIQR TO GOMMENC�MENT. RENOVATIONS MAY REQUIR A SITE PLAN. i DATE:� �O I __SIGNATURE: IG� � PR1NT NAME& TITLE: �R�'�� T�� F,� ��. . t�L�l '�Xr`' _ ' , - Rev. 11103119 j � � � The Commonwealth ofMassachusetts j Department of Industrial Accidents Office of Investigations � ' 1 Congress Street, Suite 100 ' Boston, MA 02114-2017 � www.mass.gov/dia i Workers' Compensation Insurance Affidavit: General Businesses � Applicant Information Please Print Legiblv iBusiness/OrganizationName:'�n�uin5 � �e � ✓�a rn ( (�S(d.0 �C'CX7� � ) Address: J�IGI �i�iOU�� ,�-$ �I City/State/Zip: , (l Y�'Yl�n,`f� fa�13 Phone#: �� - `j7� -�7�`j i Are ou an employer? heck the appropriate box: Business Type(required): 1.� I am a employer with�emptoyees (full and/ 5. ❑ Retail - � * 6. I�estauranUBar/Eat'�Fstablishment il _ —__ _ _ - 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 the'u right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other � *Any applicant that checks box#1 mus[also 511 out the section below showing the'v workers'compensatio¢policy information. **If ihe coipornte officers have exempted themselves,but the cocporation has other employees,a workers'compensation policy is required md such an olganizatiou should check box#1. I am an empinyer that isproviding wornkers'compensation insurance for my employees. Be[ow is thepolicy information. Insurance Company Name:�nU2 i�15�' �Q t�� C��S , Insurer'sAddress:��b.�� y ��o�� - �a�a' City/State/Zip:�k YGL1�'ttYeZ�, frnQ � IagJ' Policy#or Self-ins. Lic. # ('1��b ��"J q$ Qb� (� Expiration Date: I ( � Attach a copy of the workers' compensation policy declaration page(showing the poticy number and e piration date). -----�'ailure to secarc ceverage as reyui�ander Section2c s �ft��rr t.-1S2can-lead to Yh�irngositian af criminal_ggnaities-�fa-- _ 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 Invesrigations of the DIA for insurance coverage verification. ' I do hereby certify,und the pains and penal ' perjury that the information provided above is true and correct. S�ature•.Y � /U Date• ��I�n I�� II �— � I Phone#: � ' �� - � � �j Offacial use only. Do not write in this area,to be comp[eted by eify or town officiaL 'i City or Town: Permit/License# � Issuing Authority(circle one): � 1.Board of Health 2.Building Department 3.Cily/Town Clerk 4. Licensing Board 5. Selectmen's Office � 6. Other Contact Person• Phone#: www.mass.gov/dia l .. . � . . ... .._. _ . � 4' YA �� `�o TOWN OF YARMOUTH 0 '"3 1146 ROUTE 28 SOUTH YARMOUTH b4ASSACHUSETTS 02664-4451 N MATT/1CM[ES � �y�„�� a,�n� Telephone (508) 398-2231, Ext. 1241 — Fax (508) 760-3472 B O A R D O F H E A L T H ' � � y� p1,W►�,Q,�, � /��i.c,c�.c-ou `�-�"' �" 0�� yLe,w ��- ° M��h2o, 2o�5 ,p,n, ui � Go �-� scs�ap LLCr. P � � de urWs -��e �r �j� Arthur N. Luke/Inside Scoop LLC /}' �� 1�"rN�l�//"'� d/b/a Penguins Ice Cream Igloo J 519 Route 28 West Yarmouth, MA 02673 Re: 2015 Application for Licensing Dear Mr. Luke, Thank you for submitting the 2015 renewal application for the Peguins Ice Cream Igloo permits issued through the Health Department. While processing the license application, I noticed that the common victualler and frozen dessert license fees unfortunately had not been billed along with the food service license fee. Please remit a check to the Health Department for the$100.00 owed($60 for the common victualler license; $40 for the frozen dessert license)at your earliest convenience. The check should be made payable to the Town of Yannouth. As soon as our office receives your payment,we will be able to issue the permits to you. If you have any questions on the above, please feel free to contact the Health Department at (508)398-2231,ext. 124 L I apologize far any inconvenience this oversight may have caused. Thank you for anticipated cooperation. Sincerely, .�%%�� Mary Alice Florio Principal Office Assistant cc: file �'�V�I�.�'"�'�'^"''�� Pl� V�� e`'�``�° . �� - � '� �`ea.`.r� �`' �� 9 `s� g- 9 `� �-�7��