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Home My WebLink AboutApplication and WCr I ; �,...� ° C��MC�D ' a TOWN OF YARMOUTH BOARD OF H�AL'FH '' �� APPLICATION FOR LICENSE/PERMI��,1�� Utl:�� (U 14 . � `� * Please complete form and attach all necessary documer�ts by r Failure to do so will result in the return o#'your applicaribn pa EPT. ESTABLISIIMENT NAME: C Z TAX ID: i LOCATION ADDRESS: S-7 ��22 (�LC TEL.#: - S MAILING ADDRESS: b L� 342 A�J��S �_ �� E-MAILADDRESS: VIKE✓�-� L."W�TdH/�SUN C �OC. � COYI� M . OWNERNAME: f�l!W\C,� C. � TO�-l/�l��tn CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#:�Of'rZ�b-C902S MAILING ADDRESS: POOL CERTIFICATIONS: i The gool supervisor must be certified as a Pool�Dperator,as required by State law. Please list the designated___- Pool Operator(s) and attach a copy of the certification to this form. 1. 1��,� 2. Pool operators must list a minnnum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary 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 f►le at your place of business. 1. {� U��i 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 Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. The Health De artment will not use ast ea rs'records. Please attach copies of certification to this application. p p Y You must provide new copies and maintain a file at your establishment. 1. �� ISC 2. �, • - — --- 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 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 Tile at your establishment. 1. I`t/� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich IVtaneuver 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 Deparhnent 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 M07'EL $I10 INN $55 CAMP $55 SWIMMINGPOOL$ll0ea. =LODGE $55 [�'� -`' _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# �1�fENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $125 .X.CONTINENTAL $35 NON-PROFIT $30 . >]00 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 $ll0 NAMECHANGE: $15 AMOiJNTDUE _ $�1'�C7't`7 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** S S .Uv ADMINISTRATION Undex Chapter 152, Section 25C, Sabsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to aperate a business if a person or company does not have a Certificate of Warker's Compensation Insurance. THE ATTACHED STATE WORI{ER'S CQMPENSATION INSUKANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, pR CERT. OP INSURANCE ATTACHED ✓ OR WORKER'S CdMP.AFFII7AVIT SIGNED AND ATTACFI�D Town of Yarnaouth ta�ces and Tiens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPT2IATELY IF PAII}: YES � NQ M4TELS AND OTHER LODGIlYG ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be ' limited to the temporary and short Carm accupancy,Qrdinarily aad custamarily associated with motel and hotel nse. 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 occnpancy of not rnore than thirty(30)days,and an aggregate of not more than ninety{90}days cvithin any six{G}month periad. LTse nf a guest unit as a residence or dwelling unit shall not be considered transient Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c, 64G or 830 CMR 64G, as amended, shall genecally be aonszdered Transient. POOLS POOL OPENING: All swimming,wading and whirJpools which have been closed for the season rnust be inspected by the Health T3epartment prior ta opening. Contact the TieaIth Department ta schednle the inspectian three(3} days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a 8tate certifisd lab, and submitted to the Heaith Department three (3) days priar to opening, and quarterly � thereafter. POOI.�L�SING: Eveq�outdoor ia gcound swirnming poo:must be drained or covered within seven{7)days of alasing. FOOD S�RVTCE SEASONAL FOQD SERVICE OPENING: All food service establishments must be inspeeteci by the IiealCh DeparCment prior to opening. F'lease contact the Health Departrnent to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyane who caters within the Towu of Yarmouth rnust notify the Yannouth Heaith I}epartment by filing the reqmred Temporary Food Service Application fornl 72 hours prior tp the catered event. These farms can be obtained at tha Health Departrnent,or from the Town's website at w�vGv.yarmauth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts mnst be tested by a State certified lab prior to apening and monthly thereaftar,with sample results submitted to the Heaith Department. Failure to do so will result in the suspension ar revocation of your Frazen Dessert Permit until the above terms have baen met. OUTSIDE CAFES: Outside cafes(i.e.,autdoor seating with waiteriwaitress service},must have priar approval from the Board of Health. OUTDOOR COOKING: _ _ _ _ _ dutdoar coaking,preparation,Ur display of any food product by a retail or food service establisfunent is prohibited. NOTICE:Pernuts run annuaily fram January i to December 31. IT IS YOUR RESPQNSIBILITY 1'O RE"I'tJIZN THE COMPLETED REN�WAL APPLICATION(S) ANll REQUIRED FEE(S) BY DECEMBF,R 15, 2014. ' ALL RENOVATIONS TO ANY POOD �STABLISHMENT, MOTEL OR POQL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS M Y REQt3IRE A SITE PLAN DATE:-------�� SIGNATtJRE: � F T NAME& TITLE: c Rev. 11/03/14 l � ��.. r � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigalions ' I Congress Street, Suite l00 Boston, MA 02II4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses i Apnlicant Information Please Print Legiblv I -� ( Business/Organization Name: 11 �G/�G� h _GR !2�/ L �vu Address: I S 7 I -7�R 12 V ��1VGN vG— City/State/Zip: �,S �/�-2,NOU?N Gb�6 Phone #: (�o�) / I� Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-rime).* 6. ❑ RestauranUBaz/Eating Establishment 2.� I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. 8. Non- rofit [No workers' comp. insurance required] ❑ P 3. We aze a co oration and its officers have exercised 9. ❑ Entertainment ❑ rP their right of exemp6on per c. 152, §1(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. inswance required]* 11.0 Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other L O C{G� •Any applicant that checks box#1 must also&11 out the sec[ion below showiag the'v worlcecs'compensation policy informafioa. **If the cocporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is requ'ved and such an organi�ation should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy 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 number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries 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 Investigations of the DIA for insurance coverage verificarion. I do hereby ce ' ,un er the pains and penalties of pesjury thai the infarmation provided above is true and correct. Si ature: �� ' Date: �a o /�� Phone#: ��)a e G� a Official use only. Da not write in this area,to be completed by eity or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Hea1tL 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia