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Home My WebLink AboutApplication and WC , , WiNflCUF�._._,� � � TOWN OF YARMOUTH BOARD OF HEALTH ` ' � �� APPLICATION FOR LICENSE ��2Biti5�^� �r�;� , � ?(?�5 � " * Please complete form and attach all necessa�e��bece�ber 15.2014. � Failure to do so will result in the return of your application packet. V` _� ESTABLISHMENT NAME: Wi NA 2/GT M l�7"f: TAX ID: ' LOCATION ADDRESS: //5 R U U Tc ZS�, TEL.#: � �S�—`//7 9 ` MAILINGADDRESS: i.✓�ST X'ARMmJ77-/ MA D�J � E-MAILADDRESS: �9C fIRl��}n1 e� �!-D�R1H/G- �A�y . OWNER NAME: Y�h oMAS .�- /�fi42 Y f A!�/,A�1 CORPORATION NAME (IF APPLICABLE): /�1ARMA R lS CDR � MANAGER'S NAME: MA.2 � f12�A-,.l 'rEL.#: So8- �e 9 - a5c� MAILING ADDRESS: j � SToivFY��A/�LTL�^f; �I g ��5 U� 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. _ _�<i/L�./ �_ �,�Df1'Y1� -__—____- 2. _ _ _ _ __ Pool operatars 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 prov►de new copies and maintain a file at your place of business. i. N/A �{R�I�rJ a.� P �� 3. �F 2�;�n�nlF 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 application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your estab(ishment. 1. 2• PERSON IN CIIARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. - _ _- - - j:_ __ �_ 2. 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. 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 REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L�CENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $I10 -JL/S 03`f INN $55 CAMP $55 �SWIMMING POOL$l IOea�/,r 6,ST,> _LODGE $55 _TRA[LERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 �CONTINENTAL $35 �!S-l32 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ ZSS.O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � , _, ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Tpwn pf Yannauth is naw requiced ta hold issuance or renewal of any Iioense or permit to operate a business if a person or company does not have a Certificate of Worker's Campensation Insuranca. THE AT7'AC�IED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEll, OR C�RT. OF INSURANCE ATTACHBD ✓ 'TD �j��(1� OR WOR.KER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens tnust be paid prior to renewal or issuance of your permits. FLEASE CHECK APPKdPRIATELY IF PAID: YES '� NQ MOTELS AND OTHER LODGING ESTABLISHiVIENTS TRANSIENT OCCUPANCY: For purposes oi'the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and shnrt term occupancy,ordinazily and customarily associated with motel and hotel use. Transient occupants anust have and be able ta demanstrate that they maintain a principai piace of residenca elsewhere.Transient occupancy shal]generally refer ta cantinuous occupancy of'not rnore than thiriy(30)days,and an aggregate of not more than ni,nety(90)days within any six(6}mpnth period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. C}ccupancy that is sut�ject to the collection of Raam flecupancy Excise, as defined in M.G.I.. c. 64G or 830 CMR 64G, as amanded, shall generally be considered Transient. POOLS P(}t1L OPENING;Ail swimmang,wading and wl3irlpools which have been ciosed for the season rnust be inspected by thc Health Department prior to opening. Contact the Health Department to schedule the inspection t6ree(3) days priar to opening. PLEASE NC}TF,: People are NCtT allowed to sit in the goal area until the poal has been inspected and apened. POOL WATER'["ESTING: The water must be tested far pseudomonas,total coliform and statadard plate count by a State certified lab, and submitted to the Health Bepartment three (3) days prior io opening, and quarterly thereaHer. P4ClL CLOSING: Every autdaar in graund swirnming�ooi rnust be flrained or covered within seven(7)days of closing. FO011 SFRVICE SEASONAL FOOD SERVICE OPENTN(>: Atl food service establishxnents must be inspected by Ehe Health Department prior ta opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICX: Anyone who caters within the Town of Yarmouth must notify the Xacmouth Health Department by filing the reqwred "t'emparaxy Faod Service Applzcation form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or fram the Town's website at www.yaazmt outh.ma.us under Health Department, Downlaadable Forms. F120ZEPI DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly thereafter,with sample results submitted to the Healttt Department. Failure to do so will resuli in the suspension ar revocation of your Frozen Dessert Permit until the abave terms have been met. OUTSIDE CAFE3: Qntside cafes(i.e.,outdoar seating with waiter/waitress service),must have priar appraval from the Board of Health. OUTDOOR COOHING: Outdoor eooking,prepazation,or display of any faod product by a retail ar food service esYablishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOITR RE3PONSIBILITY Td RE'F`I7RN THE CQMPLET�D RENEWf1L APPLICATION{S)AND REQUIRED FEE(S}BY DECEMBER 15,24i4. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL dR POOL (i.e.; PAINTING, N�:W EQUIPMENT,ETC.},MU3T BE REPdRTED TO ANI3 APPRQVEI7 BY THE BOARI?OF HEALTH PRIOR TO COIvIMENCEMENT. RENOVATTONS MAY REQUIRE A SITE PLAN. DATE:__r��[��i SIGNATURE: � PRINT NAME& TITLE:_ �. _ R �J�, �� Rev. (!l43fi4 � � � - __ _= N(JTICE NOTICE _ TO � a TO EMPLOYEES a EMPLOYEES JV V The Commonwealth of Massachusetts DEPARTMENT OF 1NDUSTRIAL ACCTJ�ENTS 1 Congress S�reet, Suite 100, Baston, Massachusetts 02114-2017 617-727-4900 - http://www.state.ma.us/dia As required by Massachusetts General Law, Chapter 152, Secrions 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: WESCO INSURANCE COMPANY NAME OF TNSURANCE COMI'ANY P _O . BOX 105010 , ATI.ANTA GA 30348-5010 ADDRESS OF INSURANCE COMPANY WWC3091320 4/24f2014 - 4/29/2015 POLICY NL7MBER EFFECTIVE DATES NAME OF IN5T)RANCE AGENT ADDRESS PHONE# EMPLOYER AbDRESS EMPLOYER'S VVORKERS' COMPHNSATION OF�ICER (IF ANY) bATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of empioyment to fiunish adequate and reasonable hospital snd medical services in accordance with the pmvisions of the Workcrs' Compensation Act. A copy of the First lteport of Injury must be given to the injurcd employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has artanged for SUGh attention at the NAME OF T�OSPITAL ADDRESS TO BE POSTED B'Y EMPLOYER