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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH ��' �� o � � APPLICATION FOR LICENSE/PE�' ;��5�� r� D 1 YO14 * Please complete form and attach all necessary i�ocum �ts y Dece r IS 2 bEPT. Failure to do so will result in the return of ynur applicafion p et. ESTABLISHMENT NAME: ' ' • - � � ' LOCATION ADDRESS: o`IS - � TEL.#: q I MAILING ADDRESS: �f '� � '� E-MAIL ADDRESS: � � OWNER NAME: CORPORATION NAME(IF PPLI ABLE): C�,Oe ('f1,�rfyrti.r.r � I.LC MANAGER'S NAME: C � ' TEL.#: .p , MAILINGADDRESS: o`ZS`� �r-Rt L�/ ��M� � 2�j�.� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. -- ----- - - _-- _ _ _ _ _ _ _ _ _ -- l. 2. I Pool operators must list a minimuxn of two employees currendy certified in basic water safety, standard First Aid ' and Community Cardiopulmonary Resuscitation (CPR), hauing 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 £ile 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 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. 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 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 Establishxnents, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to ttus 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 establishxnents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 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 file at your place of business. 1. 2, 3. 4. RESTAtIRANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMINGPOOL$ll0ea _LODGE $55 =1RAILERPARK $105 WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED EEE PERMIT# 0-100 SEATS $125 _CONT[NENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RES[D.KITCHEN $80 RETAIL SERVICE: . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 �<Z5,000 sq.ft $I50 _FROZEN DESSERT $40 �TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ 2(oO. pp *•***PLEASE TURN OVERAND COMPLETE OTHER SIDE OF FORM***•* ��d �I�S� c,Q�-t�Sb28 t�o t I�� ` 1 ADMINISTRATION Unde�'Chapter 152, Section 25C, Subsection 6,the Town af Yarmauth is now required to hold issuance or renewal of any Iicense or permit to operate a Businass if a person or company does not have a Certificate of Worker's Compensadon Insurance. THE ATTACFIED STATE WORKEI2'S CQMPGNSATION INSURANCE AFFIDAVIT Mi7ST BE COMPLETED AND SIGNED, OR CERT. OF INSTJRANCE A1'TACHED OR WdRKER'S Ct7MP. AFFIDAVIT SIGNED ANL3 ATTACI-IED� Town of Yarmouth taxes and liens must be paid prior to renewal or issuanae of your permits. PLEASE CHECK APFROPRIATELY IF PAID: YES_._�__. NC! Mt3TF.LS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiT1'ANCY: For pwrposes of the limitations of Motel or Hotel use,Trr�ns'ient occupancy shail be -- -- limitad to the temparary and short term occupancy,ordinarily and custornarily associated with mote}and hotel use. Transient accupants must have and be abie ta demanstrate that they maintain a principal place of residence elsewhere.Transient oocupancy shall generally refer to continuous occupancy ofnot rnore tharntivrry(30)days,and an aggregate of not more than ninety(90)days within any six(6}month periad. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that 3s subject ta the collection of Raom 4ccupancy Excise,as defined in NI.G.L. c. 64G or 830 CMR 64Ci, as amended, sha11 generally be considered Transient. POOL3 POOL OPENING:Alt swimming,wading and whirlpoo3s which have been closed for the season must be inspected by the Health Deparhnent prior to opening. Contact the Health Departsnent to schedule the inspection three(3) days prior to opening. PLBASH NOTE: People are NOT allowed to sit in the pool area untii the pooi has been inspected and opened. POOL WATER TESTING: The water mast be tesCed for pseudomonas,total coliform and standard plate count � by a State certified lab, and submitted to the Health Department three (3} days prior to opening, and q�zarterty thereafter. POOT,CI.QSING:Every autdoor in ground swimming poal must be drained or covered within seven{7)days of closing. __ FO011 5EI�VICE _ SEASONAL FOOD SERVICE OPENING: All food service establislunents must be znspected by the Health Departrnent prior Ya opeuiug. Please contact tha Health Departrnent to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Xazmauth Health Department by filing the required Temporary Fnod Service Applicarion form 72 haurs prior ta the caterefl event. These forms can be obtained at tha Health Llepartment,or fram the Town's website at www.�armouth.ma.us urider Health Department, Dawziloadable Forms. FI20ZEN DESSERTS: Fzozen desserts must be tested by a State certified lab prior to apening and monthly thereafter,wiih sample results submitted to the Health Department. Failure to do so wilt resutt in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF'ES. Outside cafes(i.e.,outdoor seatang with waiter/waitress service),must have prior approval from the Board of Health. I OUTDOOR COQHING: Outdoor eooking,preparation,oz display of any food prodact hy a retail or faod service establishment is prohihited. P(OTICE:Pernuts run annually from January 1 to December 31. IT IS YQUR RESPONSIBILITY T(}RETURN THE CdMPLETBI}RERIEWAL APPLTCATION(S}AND REQUIRL'D FEE{S}BY I?BCEMBER 15,2414. � ALL RENOVATTONS TO ANY FOdD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINT1Nt's, NEW ' EQUIPMENT,ETC.},MUST BE REPORTED TO ANI?APPR4VED BY THE BQARD QF HEALTH PRTOR TO COM1vIENCEMEN'I'. RENOVATTONS MAY RE UIRE A SITE PLAN. DATE: ►��, +�___ SIGNATLJ \..� PR1NT NAME& TITLE: Rev.11f03t14 � �. � The Commonwealth ofMassachusetts Department oflndustria[Accidents Office of Investigations ' l Congress Street, Suite I00 Boston, MA 02I14-20U www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Business/Organization Name: ( ��,��-(`�',��,� (�,(, Address:�� Q,(,n �� City/State/Zip: f S �Phone#:�� . �`}-�' -�/�(pC� Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with��employees(full and/ 5. �Retail _QrR��— ----- - ---- _ _ _ _ 6. C1RestauranUBar/EatingFstablishment 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. �• ❑ Office and/or Sales(incl.real estate,auto,etc.) [No workers' comp.insurance required] $• ❑ Non-profit I 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment i their right of exemption per c. 152, §1(4),and we have �0.❑ Manufacturing � no employees. [No workers' comp. insurance required]� 11.� Health Care 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applica¢t that checks box#1 must also&ll ou[the secrion below showing the'�r workers'compensation policy informstion. "•If the cocporate officas have exempted themselves,but ffie corporalion has other employees,a workers'compensation policy is required and such an organizafion should checic box#L � � � . . . I am an employer that is providing r�orkers'compensation insurance for my em loyees. Be[ow is the policy information. InsuranceCompanyName: ��,��(,�[��J'(�/Q,/�Q �� - Insurer's Address: �� scl,l` f ln �(,�Q;/ 1S � , (� . IJQ� � �''f ��ri�s��ZIP: t,�c C lC�c _ fta.�r , �� l�rho 3 - Q o 2 a Policy#or Self-ins. Lic. # [ , �d�f�q�;�;r Expiration Date:��f I�� Attach a copy of the workers' compensahon policy declaration page(showing the policy nnmber and eapiration date). -Failare-to sesur ' �ctiax�25A nFM(:T 15� Can 1Par1 tp YI]C jlpppgjtjOII nf c.riminal��a1�9f g fine up to$],500.00 and/or one-yeaz imprisonment,as well as civil penalries 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 ttus statement may be forwazded to the Office of � Investigations of the DIA for insurance coverage verification. j I do hereby certify,under the pains andpena[ties ojperjury that the information provided above is true and conecG � . ( Si ature• Date• Phone#: ' - Officia[use an[y. Do not write in this area,to be completed by city or town o�ciaL City or Town• Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/1'own Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person• Phone#• www.mass.gov/dia