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Home My WebLink AboutApplication and WC� CG� . . _ -- ^� - TOWN OF YARMOUTH BOARD OF HEALTH �-�'��'tiz:� , �� APPLICATION FOR LICENSE F�2�14IT-2014 � ^ ` r � ��t�� CEC 0 3 Z013 * Please com lete form and attach all necess d cember 13 2013. Failure to do so will result in the retulnAf y�i,tx,ap�licaft, n p3t6�8tTH DEPT. ESTABLISHMENT NAME: d ,Yd </ TAX ID• ` LOCATIONADDRESS: 3G� R � 2b' dk�fY� oa6� TEL.#: Svd' lf/�.sS�� MAILING ADDRESS: � ,l S f�5 � / E-�.�D�SS: eci� o a�,� � � c n p, a � OWNER NAME: CORPORATION NAME,�IF , PLI�ABLE): MANAGER'S NAME: C,Gi.� C'D O TEL.#: d Man,nvG aDD�ss: `�a 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. L 2. _ _ Pool operators must list a minimum 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 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 applicafion. 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. i. _�U�,A ��U�/�.t) a. ALLERGEN CERTIFICATIONS: All food service establishments are 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 �le at your establishment. l.�u CDho/C�n z. �%'��.L[,/r.� �� '�i�Jl�, � � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heixnlich 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 Deparhnent will not use past years'records. You must provide new copies and maintain a file at your place of business. " i 1.�r.�.�;[��Cc� f/1�'r11'^' �?�'%�y 2. 3. 4. RESTAURANI' 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 $55 �D1N $55 CAMP $55 SWIMMINGPOOL�$SOea. _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $85 _CONTINENTAL $35 �NON-PROFIT $30 � -ly"10 Fi � _>100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 � RETAIL SERVICE: . - � � =RESID.KITCHEN $80 LICENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 -�ROZEN DESSERT $40 _TOBACCO $95 I,�' NAME CHANGE: $15 AMOUNT DUE _ $ /t!I ,u V —c�+— °**•*pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** . � ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MLJST 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 OTHER LODGING ESTABLISHMENTS - - _ _ _ -- ----- --- ____ _ - - - TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinazily 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 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 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 Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE: People aze NOT allowed to sit m the pool area 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 Deparhnent 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 SERV"ICE _ ___ - - 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 Yannouth must notify the Yatmouth 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.yannouth.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 Depar[ment. 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: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 13, 2013. , 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 REQUIRE A SITE PLAN. � � ;� DATE:�I�• I�.� rI� SIGNATURE: '�� . C[. , ��-� .x��'�' , �� PRINT NAME&TTTLE: �t(:��tl. .t��i C-h��+�f.�;.d�-?�-- Rev. 10/08/13 : � � ` The Commonwealth ofMassachusetts - Department oflndustrial Accidents Offzce oflnvestigalions ' I Congress Street, Suite Z00 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢iblv Business/Organization Name:_(�_ ( �� '1��d �(/Q,� D/yJ �'J f Address: �f.3 EA�L cST. City/State/Zip: Phone #: ��/�. ��J� (O�`� � a Are you an employer. Check the appropriate box: Business Type(required): L� I am a employer with�� (.� �employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBaz/Eating Estab;;shment 2.❑ I am a sole proprietor or parmership and have no 7. � Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. ,�,! [No workers' comp. insurance required] $• �i�"Non-profit 3.❑ We are a corporation and its o�cers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization,staffed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other *My applicant that checks box Itl must also fill out the section below showing the'u workers'compensation policy information. *'If the wrporate officers have exempted themselves,but the corporation has other employees,a workers'wmpensation policy is required and such an � organization should check box#1. � � .� I am an emp[oyer 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 expiration date). Failure to secure coverage xs requued under Section 25tY of MGL c. I52 car,lead to the imposifion af crininal pena:ties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifica6on. I do hereby certify,under the patns and penalties ofperjury that the information provided above is true and correct. Sienature• /n- I/h� Date r Phone#: � � �.�� , �, ( � � ��`� Officia[use only. Do not write in this area,to be completed by city or town officiaL City or Town: Yq{�n t�M Permit/License# Issuiu i (cirde one): . oard of Health .Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Coutact Person: Phone#: �p8-:34R-d�3l xI L�l www.mass.gov/dia • • t�s�.� NOTICE � � NC}TICE TQ � o TO . EMPLCIYEE� aW EMFLfJYEES m� � y\ �,� Sy8 The Cammonweaith of Massachusetts DEPARTMENT OF INDUSTRIAL AGCIDENTS b00 Washington Street, Bostan, Massachusetts 021i1 617-127--4904 -- httg:/lwww.mass.gavldia As r uized by Massac6usetts General l.aw,Chapter 152,Sections 21,22 8c 30,this wr11 give you notice that I�(we) have provided for payment to our injured employees under the above mentioned chapter by msuring wtth= 7FE Tt2AVELERS INSlN2ANCE Ct�lWFE5 NAME OF irISLJRANCS COMPANY P.O. BOX 1450 MItX}i_E60R0 MA 02344-145p ADI7RESS dF INSUI2ANCE COMPANY (7PJU6-5643q07-7-13) 06-3Q-13 TO 06-30-14 POLICY NUMBEB EFFECTfVE DATES .� �� WM F BORt€K iNS AC�NCY 37 f PLVMCXlTH STREE7 � �� HALIFAX MA 02338 � N.AIYTE OF INSU22ANCE AGENT' ADDRESS .— PHC?NE# �� 83 Peazi Street a,�, CdPE COO GF#ILD I�VE�tIPD�NT HYallnj$� � PROtlZAM INC �a2�� o� _.. � � EMPLOYER ADDRESS <_. � �� .� EMPLQYER'S WORKERS COMPENSATION£}FFICER{IF ANY} BATE � 14�EDIC.AL TREATI��ENT ^� The above named insurer is required an cases of persc�aal injuries arising out of aad ia the course of � earplayment to furaish adequate and reasonable hospital and medical services in accordance witlt the � pravisions af the Workers' Compensation P,ct A copp of the Fust Report of Injury must be given to the �'.— injured employee_ T'ha emptoy� may select his or har own physician T'tre reasonable cost oE the services � provided by the treating physician wiQ be paid by the insurer, if the treatment is nec:essary and reasonably � conneeted ta the work reiated injnry. In cases requiring hczspita2 attention, employees are hereby uakified that the insurer has arranged for such attention at the Cape Cod Hosgital 508-171-18Q0 21 Park Street,$yaunis,MA q�6Q1 NA14IE QF'HCfSPTI'AL ADDRESS �„� ,,,�P,�,2 TQ BE Pt�5TED BY EMPLt3YER