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Home My WebLink AboutApplication and WC � • D �DC-J � , � � � TOWN OF YARMOUTH BOARD OF HEALT i;- _ j,�';y. RE ScN�o o c, , APPLICATION FOR LICENSE/PE IT-20 �. , • `�C0720i2 � ' * Please complete form and attach all neces� � f ` y c ber IS 2012. ` ` Failure to do so will result in the return yq't�r S�p�i. at�i REPT. � y,_' " ESTABLISHMENTNAME: G�pe�dCti; Id �e��oMP.,T TAXID: � LOCATIONADDRESS: 36`� Ro�rc a 8 �J.£Ya��.o�rti ►��} TEL.#: S08 �II f3 SS��1 MAILING�DRESS: r3 .3 Pe0.r I .S? . I� Y ahn,_5 M f� Da 60� UWNER NAME: o. t Go h•` l e .+ c I o r-, �., r CORPORATION NAME (IF APPLICABLE): Go. e Co� �� r✓G lo r�P.. r MANAGER'S NAME: r c l2� TEL. : B S `J MAILING ADDRESS: . ) � a nh � 6 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. t. _ 2. _ -- -- Pool operators must list a minimum 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 �le at your establishment. 1. ��'1 (� 1^P�./ /��/ s 2. i PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1._��'��./ /` S 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. f'fV��r'rir..J /� �� S 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 $SOea. _LODGE $55 _TRAILERPARK $105 WHIRLPOOL $80ea. � FOOD SERVICE: ..---�--- --� ------ - -----._.. --- —�— --__-- -------- LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# _0-100SEATS $85 _CONTINENTAL $35 � NON-PROFIT $30 �/3-b�7 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREll FEE PERMIT tk LICENSE REQUIRED FEE PERMIT# _<SOsq.ft. $50 >25,OOOsq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOiJNT DUE _ $ 30.pp � *****PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM***** � ADMINISTRATION t ` . Under Chapter 152,Section 25C,Subseciion 6,the Town of Yarmouth zs now required to hold issuance or renewal of'any license or permit to aperate a business if a person ar company does not have a Certificate af Worker's Compensation Insuzance. TIiE ATTACIIED STATE WORKEIt'S COMPENSATIt3N INSUItANCE AFFIllAVIT 1VIUST l3E COMPLETED AND SIGNED,OR � � CERT. OF INSURANCF AfiTACHED OR f WCJRKER'S COMP. AF�FIDAVIT SIGNED AND ATTACHED V Tawn of Yannouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YB3 NQ� MOTELS AND OTHEIt L4DGING ESTABLISAMENTS „ . ,. TRANSIENT QCCUPANCY. Por purpases of the limitations of Motel ar I-Iote(ase,Transient occnpancy shali be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient accupants must have and be able to demonstrate that they maintain a principal place of residence e3sewhere.Transient occupancy shall generally reSer to contSnuous occupancy of not mare than thirty{3d}days,and an aggregate of not more than ninety(40)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 Raom Occupancy Excisa, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considereB Transient. POOI.S POOL OPENING: All swimming,wading and whirIpools which have been closed for the season must be inspected by the Health Deparhneiat priar to apening. Contact the Heaith Department ta schedule the inspection three{3}days prior to opening.PLEASE NOTE: People are N01'allowed to sit in the pool area until tha pool has been inspected and apened. POOL WATER TES7'ING: The water must b�tested for pseudomonas, total colifarm 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 musf be drained oc covered within seven(7)days of ciasing. FC?OD SE12VI�E SEASONAL F40D SERYICE OPENING: All food service establishments inust be inspected by the Health Departznent prior to opening. Please contact the Health Department to schedule the inspection three (3)days prior to opening. CATEI2ING POLICY; Anyone who caters within the Toum of Yarmouth must notify the Yarmouth Health Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the F Tealth Department,or fram the Town's website at www.yarmouth.ma.us under Health Depai�nent, Downloadable Porms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified tab priar to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to da so will resnit in the suspension or revocation of yaur Frozen Dessert Permit until the above terms have been met. OiJT3IDE CAFES: Outside cafes(i.e.,outdaor seating with waiteriwaitress service},must have prior approvai from the Baard af Health. OUTDt}OR Ct}QKING: Outdoar cooking,preparation,or display af any food product by a retail or food service establishment is prohibited NCl TICE:Permits run annnally&om January 1 to December 31. IT IS YOUR RESPC?NSIBILITX TO RETURN THE GOMPLE'T'ED RENEWAI.APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER I5, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMEN'I', MOTEL OR POOL {i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENC7VATIC3NS MAX REQtIIRE A STTE PLAN. DATE: i i,_►�� ► �- SIGNATURE: A r �} PRINT NAM$ & TITLE:_,,� C.W I�`� 5 - ✓fi'r i T"I'o v� Rev.10/09/12 (.,...0(9 �''Ol��/�0. tl�r �. Y � � The Commonwealth of Massuchusetfs Department of Industrial Accidents Offace of Investigations 1 Congress Street, Sttite 100 &osion,MA Q2114-2P17 wrow.mass.g�+v/dia Workers' Compensa[ion Insurance Affidavit: General Businesses Asrulicant Information Please Print Legibtv BusinesslOrganizatianName:�'e �0� �1"� �p� L/e�1e �� M P`"t �" Address: � .3 (` e'�� q City/State/Zip:_.��an��'s� MfF Oa60 Phone#: S_O � ' � � a � �S� I Are you an employer?Check the appropriate bas: Business Type(required): I.� I am a employer with �0� r=Cmnloyees(full andl $� ❑Retail * b.�Res[auranv'rsarrF,ating fisiab3'rsnni8nt " or pari-fiznej. 2.❑ I am a sole proprietor or parmersh'rp and have no 7, �pffice and/or Sales(incl.real estate,auto,etc.) empioyees working for rne in any oapacity. g, �p Non-profit [No workers' comp. insarance required] 1+�' 3.❑ We are a corparation and its afficers have exercised 9. ❑Entertainnrent their right o£exemption per c. 152, §1(4),and we have 1Q.0 Manufacturing no employees. [No workers'comp.insurance required]• I LD Health Care 4.❑ We are a non-prafit organiaaYion,staffed by vo3uztteers, with no ernployees. [No workers' comp. insurance req.j IZ•Q Other *My app6cant that checks box#1 must atso fitl out the section betow shawing thev workers'compensation policy information. *"if the cocporate officers have exempted chemselves,but ihe coeporation has uther employees,a workers'compe�satiun policy is required and such an , organi�fion should check boxfit. I am an emptoyer rhat is providing warkers'camgensation Fnsurance f�r my e7npioyees. Betow is the patiey infor�iton. Insurance Company Name: �Y�A V G �t� $ Insurer's Address: P� v . �Q k �� C��Is�t�Z��: r�;�(d I� b�� r�► �t- 0�3�-f y�r�s-o Policy#or Seif-ins.Lic.# � t" ��,��y 300�-?—�� Expiration Date: (�.3�..�13�' Attach a copy of the workers' compensation po6cy declaratiou page(showing the policy number and exp�rafioa date). Failure to sacure coverage as requ'ved under Secrion 25A of MGL a 152 can lead to the imppsition of criminal penalties of a £maug tQ$L,S44.44andtor4uue-year imgris�al�n4 as��lLas.. ��GI_.]oenalties in th_e fore�of a STOP WORK 4RDER_and a fine __ af up to$250.00 a day against the violator. Be advised that a copy af this staternent may be forwarded to the Office of Investigations of tha DIA for insurance coverage verification. I do heteby certify,under thepains uedpenatties ofperjury that the infi�rmation provided above is true and conect. 5ignahu�e- ��___�� Da�`�S�� Phone#: � ` � � 8 � �S� Officiat use oxty. Do not write in this area,to be compJe[ed by city or[own offreiaL City or Town: �LF2MOU41� Permit/License# Issuin circle aue}: 1 oard of Healtt .Building Department 3.CitylTown Cierk 4.Licensiag Board 5.SeMctmen's Office 6.Qther ContactPerson: Phone#: �t'�3Qj�r3a;�i � X�Zy� www.mass.gov/dia