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HomeMy WebLinkAboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH � , � ��� APPLICATION FOR LICENSE/PERMIT - 201 � �.. � MaY o< �;� � * Please complete form and attach all nece o ent ' mber IS 201�`. ` Failure to do so will result in the re app�ic� a_ �t vf _ ;�^� ESTABLISHMENT NAME: I TAX -� LOCATION ADDRESS: TEL.#: MAILING ADDRES, $: OWNER NAME: Y'C�0. L� Yl CORPORATION NAME( APP ICABLE): MANAGER'S NAME: (�i VDl1 TEL.#:�']4—�a,I— lpd`�7 MAILING ADDRESS: 1�bY1� WQu ��yrl'h (�j�,j���yj Y4 n 2(�1p� 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 muumum of two employees currently certified in basic water safety, standazd 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 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 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. 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 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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# /� OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMPC# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMWGPOOL $80ea _LODGE $55 _'fRAII,ER PARK $105 _WHIRLPOOL $SOea FOOD SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 _>100SEATS $160 �COMMONVIC. $60 ��a"��0� _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICEIVSE REQUIRED I^'E PERMIT# LICBNSG REQUIRED FEE PERMTT# ��� _<50 sq.ft. $50 _>25,000 sq.f[. $225 _VENDING-FOOD $25 _QS,OOOsq.ft. $80 LFR07.ENDESSERT $40 � '�I _TOBACCO $95 tvnmE cxnivcE: $�s AMOUNT DUE _ $ /Od, DO ****"PLEASE TURN O`JER AND COMPLETE OTHER SIDE OF FORMxk•+* ADNIINISTRATION � , 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, OI£ CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED Town of Yazmouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonsuate that they maintain a principal place of residence elsewhere.Transien[occupancy shall 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 uansient. 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 Deparunent prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PI.EASE NOTE: People aze NOT allowed to sit 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 standazd 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 closutg. FOOD SERVICE SEASONAL FOOD SERVICE OPEIVING: 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 Yazmouth 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 Depamnent, 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 Departznent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut untIl the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepaza6on,or display of any food product by a retail or food service establishment is prolubited. 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 I5, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAII�tTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU A SITE PLAN. DATE: /02, SIGNATURE: �iL<"_�' �CLf` / PRINT NAME&TTI'LE: � 2� �. `/Q�'J ' �W�►" Rev.]0/25/11 . .._.____.____. _..._------i PBYchex use only(please print). ' � ' Agency Represenwtive: Kim Marianetti (D5i9) � Client Information Telephoue:(�.ZL)�5§--�$$Q_Ext.�$4Q2 j sis m: a�eava2 Brancl✓Ctient Number. ,_q_� ,�� / — ——�— ———�—— . I Federal ID Number: ��� Legal Compa`ry Name: HOn vOx � DBA Name: AERRY TWiCTFD . Billing Address: 1 DONS WAY � City: SOLiTH DF.NMS Spte: MA Zip Code: _02bG0 � Delivery Address: � rars�rENrmwwiaovE:voeox�araTrcc�vne�esononrvem�no�as . � City: State: Zip Code: � Cotnpany ContaCt: HOA VON E-meiL'HOA.i_VONr�C1Ti7F.NSRANK.('AM Telephone: (ZZ�)32L - .(�424_ Fax: (_)_ - Payroll Frequency:�Weekly(52)�Biweekly(26) ❑Semimonthly(1A) ❑Monthly(12) ❑Other. � Controlled Ownership: O Yes No � � IfYEl.PIIOVNEALLP�YPOLLNVIlEPt!lLOYI:♦ AOqIqNKPl10EIFNECC'MPY . . Parent Office/Client p:--�—/----------- Fed ID: —— — —— — —— — Chiid Office/Clien[N: —`--/�----------- Fed ID: —-- ——— — — — — Child Office/Clien[d: ----/----------- Fed ID: —-- ——— — — — — ChiW Offlce/Client//: ____/________,___ Fed ID: _ _ _ __ _ __ _ Policy Number: UB8B225131 Pol'uy Effecdve Date: OS � 02 � 2012 � Do all employees reside in[he same s�aoe and I�ave tl�e same class code? . . � �Yes. State: MA Class Code: 8017 ❑No. (Avach Workers'Compensation Employa Classification,WC0002) Payroll Client Stawx�New O Current ❑Non-payroll Next Payroll Run Date: _/ / Bill Method: �Agency Bill O Direct Bill Premium:$ 999.00 How did the client hear about Paychez Workers'Compensation Payment Service? PIA Rep: KIM MARIANETTI � Source type: CORE SALES REP �Lead Souree Dare: OS � 02 � 1Al2 . Source oame: MATr�W BA��O ❑I�ependenl Agent p Keystone Agent Code: Commission: % Cerrler Listing � ❑ AiG Specialry-948 0 PBOA CA-868 � ❑ AmTrust-861 [] PBOA FL-737 ❑ Firoman's Fund-920 � SPT-661 � � First Cardinal-729 . � Spte FuM � ❑ First Comp-944 ❑ SLperior Acceea-756 � � Guard-660 ❑ Wusau-950 � O }isrtfotd-G34 . � Olher. TRAVELERS(P&C� PaY�x Wmkers'Cca�pensarrion Pqoem Service SeY9 Kq � W(]I001 1l09 . 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' ��������� W�4w �CM��YMflAI����10L10/�lil1/4C�/BIYMS COM.NMI�W1 RYGfYaRIM�1NPi�0.W�f Y!m1YAYtl�111 �Wtl I � � A0�17�'M�w ��� . . �R9SYMII�1 � i� I . . � . �'� The Commonwealth ofMassachusetts Departixeat ojlndustria[Accidents N�C�N�s�aGrs 600 Washington Sheet, �"F[oo� Boston,Maxc. 011ll Workers'Compeesatioa lasaraace Aflidavih� Aootleat i�twmatln• Ptear PRaI'I'kd6h name: �6�A C�oN v7 f3A Rrr'12�.y (uJ� S'1�1� address: ___—/� � ! � '��_ aS2_— —_—_ c� J � �,�lYICJ1�i1"� spte: l�l� zio: ���] ol�t# � 7�-s�l -6o9y' work site Iacation(futl addcessl: ❑ I am a homeowner perfo�ming all work myself. ❑ I am a sole proprietor ard 6ave no m�e wodcing in arry capacity. � �I am an employer pcoviding workers compensation for my employees wodcing�this job. eompuv rme: adtas: eitr' d�we M' �..�� �iz.a���2.s �r _„(//� 8 B a�S^73l .... :. ❑ I am a sole proprietor,geaersl eoetraeMr,or homeowner(nrrle nwe)and have hired the contractas lis[ed below wM have the following workers compensation polices: comour roe• ad�s• dtv' oYaee M: ieeva�eo. � ��rtuY�me: ad�• ekr• o�a�eM- fasva�ee ea oaliev M w�r.++�r.r,r�e r..e...� FaO�rc r aecvic e�eaee n rtqitN�dv SMM�2SA d MGL 132 m Isd b IYe�dv1iY ps�Mo d a me R b f1,'JKM�Ml� o�e Tean'lepr6e��eet a�wN u dH penpb 1�t!e(p�Ka ST(X WORK ORD[R ud�6e d f1M.M a d�y apimt re. 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