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
. Rep:K�Muiamui
- - - ---- - --__ . _ _ __
05i822012 15:10 DENVIS S&S i 915853897243� - FAJ.717 D01
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. �'� 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:
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.... :.
❑ 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:
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