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Home My WebLink AboutApplication and WCr , � TOWN OF YARMOUTH BOARD OF HEALTH B �� APPLICATION FOR LICENSE/PE,�RM�i�T�-2 UEC 2 9 ZO14 * Please complete form and attach all necessary do�uments�ece ber EPT. Failure to do so will result in the return of yow application p ESTABLISHMENTNAME: '�'ti� �r�•�(�.�_ C(uL TAXID: LOCATION ADDRESS: ,�oS /l76ri., Sf. Vo,� �Gi/Cbif- dl{9- TEL.#: - . MAILING ADDRESS: j'�iy /5/ , � V(`iin`�`� A-�ii�^LyJ�- //2�„7 c' E-MAIL ADDRESS: -- OWNER NAME: CORPORATION NAME�F APPLICABLE): MANAGER'S NAME: Il?uh41Z. �{'t r Ih�rc�t pies '�� ,�.r- TEL.#: 5'�-3kS'-h3S7 MAILING ADDRESS: /� ��onh S •,�� , �r1�3� POOL CERTIFICATIONS: i 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. i __ , 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. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food Protection Mana er as defined in the State Sani Code for Food Service Establishments 105 CMR 590.000. g > �'y � � , 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. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1• - - - - -___ _ 2. ALLERGEN CERTIFICATIONS: All food service establishments aze 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 file 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 Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-choking 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 �le at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# --- - - — - - ----A�F��iiS�+-AIVLY ---- -- - LODGING: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: � � � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 0-100 SEATS $125 _CONTINENTAL $35 �NON-PROFIT $30 r,,=��R , >100 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 =<25,000 sq.R $150 _FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ 30.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , . ADMINISTRATION Under Chapter 152,Section 25C,Subsecfion 6,the Tawn of Yarmouth is now required ta hold issuance or renewal of any license or permit ta operate a businass if a person or company does not have a Certificate of Worker's Compensation Insuias�ce. T�IE ATTACHED STATE W012KER'S CCIMPENSA'TION INSURANCE AFFIDAVIT MUST BE COMPLET�D AND SIGNED, OR CERT. 4F TNSURANCE ATTACHED � OR WORKER'S COMP. f1PFIDAVIT SIGNED AND ATTf1CHED Town of Xannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIA`I'ELY IF t'AID: YES__� NO MOTELS AND OTHER I,ODGING ESTABLISHMENTS TRANSlENT OC:CUPANCY: For purposes oPthe limications ofMotai or Hotel use,Transient oecupaney shall be lirnited to the temporazy and shart term occupancy,ordinarily and custcarnarily associated with matel and hotel use. Transient ocaupants must have and be able to demanstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 gei7erally refer to continuous accupancy of not more than thirty(30)days,and an aggregate o£not more than ninety(90)days within any six(6)month period. LJse nf a guest unit as a residence or dweltzng unit shall not be considered transient. Occupancy that is subject to the collectian of Roam Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR b4G, as amended, slzall generally be considered Transient. P40L5 POOL OkENING.All swimming,wading and whirlpoals which have been ciased fpr the seasan must be inspected by the Hea7th Department prior to opening. Contact the HealYh Department to schedule the inspection three(3) days priar to apening. PLEASE NOTE: People are NdT allowed to sit in the pool area until the paol has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudpmonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quazterly thereafter. POOL CL4SING: Every antdoor in ground swirnming poai must be drained or covered within saven{7)days af closing. FOOD SERVICE 3EASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Healfh Deparkment to schec�ule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the required Tamporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or frorn tt�e Town's website at www.yarmouth.ma.us under Health Department, Downlaadable Forms. Fl20ZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health DeparGment. Failure to do so will resuIt itt the suspensiott or revocatian of your Frozen �7essert Peranit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. OUTAOOR COOKING: Outdoor cooking,preparation,�r display of any food product by a retait or food service establishment is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPdNSIBILITY TO RETURN THE CdMPLETED RENEWraL APPLICATION{S}AI�1D REQIJIRED FEE(S)BX D�CEMBER 1S, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTiNG, NEW F,'QUIPMENT, BTC.}, MUST BE REPORTED'i"O AND API'ROVED BY THE BOARD OP HEALTH PRTOR TO COMMENCEMENT. RENOVATTONS MAY REQUIRE A SITF,PLAN. DATE: SIGNATURE: FRINT NAME& TITLE: Rev. ilfQ3tl4 '. � � � TheCommonwealihofMassachusetts Department of Industrial Accidents " Office oflnvestigations 1 Congress Street, Suite I00 Boston, MA 02114-20U www.mass.gov/dia Workers' Compensation Insurauce Affidavit: General Businesses Annlicant Information Please Print Leeiblv Business/Organization Name:_'�� Y; dc,�..�., � lu H Address: �l�C (�� City/State/Zip: /Yrl U.( f-G� O�f (1113 02�7S'Phone#: Are you an employer? Check the appropriate bos: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail ' or part-rime).* 6. ❑ RestauranUBaz/Eating Establishment — - __- - - --- _ _ . am a soIe proprietorbr partnership and-have no �, � Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capaciTy. [No workers' comp.insurance required] 8• �'�n-profit 3.❑ We aze a corporarion 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]* 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 fill out the section below showing their worke:s'compensation policy informazion. '•If the cocpornte officeis have exempted themselves,but the corporalion has other employees,a workers'compensation policy is required and such an organization should check box#]. I am an employer that isproviding workers'eompensation insurance for my emp[oyees. Be[ow is thepoliey information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration 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 agt�$t,500:00�far as�yeaF im}�riso�rtent,-as-well as-siu3�penalties in thg#'en�i 0fa-ST9P wnux nunRA 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 Investigations of the DIA for insurance coverage verification. I do hereby cert�,under the pains and penalties ofperjury that the information provided above is true and correct. Si¢naYure• LCG�,Yf,(�/f�l� ��L�/Y�D� �iCS� � Date /�-�0'1 3�� —� Phone#: ��— �S '�� O�cia!use only. 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. Buildiug Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#• www.mass.gov/dia