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Home My WebLink AboutApplication and WC • B�v"fw�s� • �� TOWN OF YARMOUTH BOARD OF HEALTH `� G� - ,�',;7� ��, APPLICATION FOR LICENSE/PE � �'" �R��'`�� Pf� l��iaia. : � * Please complete form and attach all�il c�s�ry documents b Dec e Failure to do so will result in th�return of your applic ion�a&�� PT ESTABLISHMENT NAME: Yr � T ID: � `� LOCATION ADDRESS: 'I r TEL.#: pY - � MAILING ADDRESS: �- OWNERNAME: 1-E� a L� `��'� -- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: (-�h 9� �-2 �/Uh TEL.#: "174 -5�I -Loo`�9 MAILING ADDRESS: 1 �ta'LS waul �� hn� � 1U W U Z1oL zl POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar/,sl and attac_h z copy of th� certificatior.io this fUrm. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. 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 �le at your establishment. 1. 2. �t EkSu`-I�I�i CAARGE: --` - -- -- ` _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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 a11 times. Please list yow 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 $55 INN $55 CAMP $55 _SWIMMING POOL $80ea. LODGE $55 TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT N LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-�100 SEATS $85 —CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $160 1COMMON VIC. $60 �I�._��QC�S _WHOLESALE $SO RETAIL SERVICE: —RESID.KTTCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.R. $50 >25,OOOsq.R. $225 p _VENDING-FOOD $25 _ _<25,000 sq.ft. $80 �FROZEN DESSERT $40 �6u _TOBACCO $95 , NAME CHANGE: $15 AMOUNT DUE _ $ l 00 .oo �_ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION ' Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTI�'E1C�LaDGIN� E�'i'�BL'IST�NIEN`I'S -- � - - = TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shor[term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy sha11 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 of 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 generally be considered Transient. POOLS POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3)days prior to opening. PLEASE NOTE: People are NOT allowed to srt m 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 State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: OutsidecafesLi,�41�td4oxseating-t�+itl�draitedwaitressserxice),musthavepp�r��al-frumt��c�sclef�kk: - OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REt� A SIT�N. DATE: I o� �l��J�2 SIGNATURE: �g (.��'� PRINT NAME & TITLE: � � �/ul�t ��wy/,e/ Rev. 10/09/12 �� NOTICE � � NOTICE TO � a TO ;� EMPLOYEES � �� EMPLOYEES eW / y �9,H 5�6 The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law,Chapter 152, Sections 21,22&30, this will give you notice that I (we) have provided for payment to our injured employees under the above me�tioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 7450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (IEUB-5C39812-4-12) 11 -01-12 TO 71 -01 -13 POLICY NUMBER EFFECTIVE DATES �� CENNAIRUS LLC P 0 BOX 25897 — SARASOTA FL 342772897 — NAME OF INSURANCE AGENT ADDRESS PHONE# <- o� VON, HOA 1 DONS WAY � o_ DBA BERRY TWISTED = SOUTH DENNIS `� � MA 02660 �= EMPLOYER ADDRESS <— o= o� EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE ' �� o= MEDICAL TREATMENT � T'he above named insurer is required in cases of personal injuries arising out of and in the course of °= employment to furnish adequa[e and reasonabte hospital and medical services in accordance with the '— provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the �- injured employee. The employee may select his or her own physician. The reasonable cost of the services a= provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably = connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS ooag,z W20P1G02 TO BE POSTED BY EMPLOYER