HomeMy WebLinkAboutApplication and WC, _ _ ---�
^ -d TOWN OF YARMOUTH BOA . I , L � �' - `
, �� APPLICATION FOR LICENSE � T-�,2�� � l='a � 3 7fJ95
.,, .
" * Please complete form and attach all necess�d c ent� y ecem er 5 20 . ..,,:,;r
Failure to do so will result in the return of your application pa �:- ---`=" ' �
ESTABLISIIMENT NAME: l - TAX ID: Z 7-5 6 8/3
LOCATIONADDRESS: sfS Yn�ivu S-f- LUF<r �/�2mu � V1�19 TEL.#: 9�8-37S-S�fo2.
MAILING ADDRESS: Sctvn c_.
E-MAIL ADDRESS: , o e - m a r ra m a QnJ a m,a, l . �a n-,
OWNERNAME: � ,/o se �h rY/i42�4tnR
CORPORATION NAME (IF APPLICABLE): S4ncl bu 2 Yr1�►Ni�9-a�/�n��v1;, 2YLG.
MANAGER'S NAME: J o s E TEL.#: 9`l f�-3 7S-S�U Z
MAILING ADDRESS: S I Ss h1✓a,x, S�-• lG ES t ���.ryw 11�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.
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), 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.
l. 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. /'»� c_�� ra�� l/�Lc.e.� _ 2. Gh�is�irva C�22�y
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. /�, �Gr �acL (/tqLEx./ 2. �h2�•s�;,�,.4 C�.e�
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 file at your establishment.
1. l� 5 �i h-ti., ! a�.e�. 2.
HEIMLICH CERTIFICATIONS:
All food service establishxnents 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 Deparhnent will not use past years' records.
You must provide new copies and maintain a �le at your place of business.
�. Pc�;��w � t� � �. c �.,�S �,-� c �y
3. avl � h PcSc�.ev 4.
RESTAURANT SEATING: TOTAL# �"� N,��Ne� mrE aor au�� `
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN � $55 MOTEL $110
IIVIV $55 CAMP $55 SWIMMINGPOOL$110ea
LODGE $55 TRAILER PARK $l05 � WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 �/.i�f3( CONTINENTAL ; $35 NON-PROFIT $30
>I00 SEATS $200 d� �/ COMMON VIC. $60 ��a. _WHOLESALE $SO
. —RES[D.KITCHEN $80
RETAIL SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED� FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 >25,000 sq.ft. � $285 VENDING-FOOD $25
=<25,OOOsq.ft. $l50 � —FROZENDESSERT $40 _TOBACCO $110
NAMECHANGE: $15 �� AMOUNTDUE _ $ /B,'��,DO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATION � •
LTnder Chapter 152,Section 25C,Subsection 6,the Town af Yarmouth is now required ta hold issuance or renawal
af any license or permit to operate a business if a person or company does nat have a Certificate of Worker's
Compensation Insurance. TFIE .ATTACHED ST'ATE WOFtKER'S COMPENSATIQN INSUI2ANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OI2
CERT. OF iNSLJRANCE ATTACHED ✓
OR
WORKER'S COv1P. AFFIDAVIT SIGNED AND ATTACHED
Tawn of Yarmouth taxas and liens must be paid priar to renewal ar issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TI2ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
lirnited to the temporary and shart term occupancy,ordinarily and oustamarrly associated with matel and hatel use.
Transient occupants must have and be able to demanstrate 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 nat be considered transient. Occupancy that is subject to the collection of Room t}ccupancy
Excise, as defined in M.G.L. c. 64G or$30 CMR 64G,as amended, sha11 generally be considered Transient.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been clased for the seasan must be inspected
by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three (3)
days priqr to opening. PLEASE NOTE"s: Peopie are Nt7T allowed to sit in the pool area until the poal has been
inspected and opened.
POOL WAT�R TES'�'ING: 'Che water must be tested foz pseudamonas,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 outdaar in ground swimming pool must be drained ar covered within seven{7)days of
closing.
FUOD SERVICE
9EASONAL FOOD SERVICE OPENTNG:
AII food service establSshments must be inspected by the Health Department prior tn opening. Please contact the
Heaith Department ta schedule the inspection three(3)days prior to opening.
CATERING P4LICY:
Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the
required T`emparary Faod Service Application form 72 haurs prior to the catered event. These forms can be
obtained at the Heaith Department,or from the Town's website at www.varrnouth.ma.us under Health Department,
Downloadahie 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 Deparhnent. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
QUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
(7UTDOOR COOHING:
Outdoor cooking,prepaxation,or display of any food product by a retail or food service estabIishment is prohibited.
NOTICEt Permits run annaally frocn January 1 to December 31.. IT IS YOUR RESPONSIBILITY TO RETtTRN
THE COMPL�TED RENBWAL APPLICATION(S)AND REQUIREI3 FEE(S} BY DECEMBEI2 15, 2014.
ALL RENOVATIONS TO ANY FOQD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPtv1ENT,ETC.}, ItRUST BE REPORTED TC}ANLt APPROVED BY THE BC}AI2D OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIQNS MAY REQ IRE A SITE P N.
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PItINT NAMB&TITLE: ,.? s h I���z�m.a CrJ
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� The Commonwea[th ofMassachusetts
Department of Industrial Accidents
Office oflnvestigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Analicant Information Please Print Leeiblv
Business/Organization Name: ��r��i� m�vc�r=�n�.�i�"
Address: SI � /nr�,z� Sf
G zG 73
City/State/Zip: l�i Es � �� Phone#: 9 �� - 3? S - S�v'z-_
Are you an employer? Check the appropriate box: Business Type(required):
1.� I am a employer with �o employees(full and/ 5. ❑ Retail
or part-rime).* 6. �Restaurant/Baz/Eating Establishtnent
2.❑ I am a sole proprietor or parmership and have no �, � O�ce and/or Sales(incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8• ❑ Non-profit
3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 1 I.❑ Health Care
4.❑ We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
•My applicant that checks box#1 must also fill out the sec[ion below showing the'v workers'compensation policy information.
**If the colpornte officers have exemp[ed t6emselves,but the corporation has other employees,a workers'wmpensation policy is required and such an
organization should check box#1.
I am an employer that isproviding workers'compensation insurance for my employees. Be[ow is the policy information.
Insurance Company Name: C/o. �E Tn s�,r.a-,�, c a A-a.e n � -
Insurer's Address: � 7� S'vv„rn c-.r �f
City/State/Zip: F•�� � !�t¢ a/u z-o
Policy#or Self-ins.Lic.# 5�1 W C �77&�� Expiration Date: �G�/ �/S
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date).
Failwe to secwe coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-yeaz 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 verificarion.
I do hereby ceRify under the pain and penalties of perjury that the information provided above is true and correct.
Si ature: Date: � /3 /�
Phone#: 5 & " 3 �s'��/v z
Official use only. Do not write in this area,to be completed by city or town officiaG
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Towu Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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