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Home My WebLink AboutApplication and WC . ,°' � TOWN OF YARMOUTFI BOARD OF L� t -� , ' C�� o �� APPLICATION FOR LICI+;NSEfPF � � t [f�� ,'� ZQ 14 �� ,� �:: e� q :� `'" * Please complete form and attach all necessary do��ne III�r��b IS 2014. Fai lute to do so wi 2 1 resu lt in t he return o f your appticahon pack . DEPT. ESTABLISHMENT NAME: ' A D• CY7 / 8" LOCATION ADT}RESS: /,�--��4�C" Ct` TEL#•�� ,��A MAILIIVG ADDRESS: �� '�'b E-MAIL ADDRESS: OWNER NAME: /�r-}��e„` rZ f� � GORPQRATION NA (IP�PPLICABT,E): MANAGER'S NAME: �-- TEL#� MAILING ADDRESS: �.---- POOL CER"I'IFICATIONS: The paal snpervisor must be certiged as a Poa(Operator,as required by State law. Please list the designated Poal Operatar(s) and attach a copy of the certification to this form. i. 2. Pool operators must list a minimurn of two employees eurrently certified in basic watar safety, standard First Aid and Community Cardiopnlmonary Resuscitatian (CPR), having one certified employee on premises at all times. Piease list the employees below and attach capies oftheir certifications to this form.The Health Department wili not use past years' records. You must provide new copiss and maintain a file at your place af business. 1. �. �• 4. FOOD PROTECTION MANAGBRS - CERTIFICATIONS; All food service establishrnents are required to have at least one full-tirne employee wha is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishznents, 265 CMR 590A00. Please attach copies af certificaiian ta this appiioatian. The Fiealth Department wiii not use past years'records. You must provide new copies and maintain � �le at your establishment. 1. �, -- --�EK:�6NP�L'FtA�f7E: . — . - —__..---__ . _ __...— .- - _ Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. 1. z. ALLERGEN CERTIFICATIC}NS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Cade for Fopd Service Estabiishrnents, 105 CMR 590.Od4(G)(3)(a). Please attach capies of certificatian to this appiScation. The Health Department wili nat nse gast years' recards. Yau must provide new copies atnd maintain a file at your establishment. 1. �, HEIMLICH CERTIFICATIONS: All food service establishrnents with 25 seats ar mpre rnust have at least one employee trained in the Heirnlich Manenver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach capies of ernployee certifications to this form. The Health Depankment will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. �• 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY L{}DGING: LICENSE REQUIRED FEE PF".RMIT# LICGNSE REQUIRE6 FEE PERMIT# LICENSE REQUIRF.p FEE PERMIT# BBcB $53 C,'ABIN $55 lv10TBL $L10 SNN $55 CAMp $55 SWIMMING POOL$210ea � 1 LODGE $55 �6;$' _1'RAILER PARK $105 �� _WHIfLLPOOL $ll 0ea.,. FOOD SERVICE: LICENSE 1tEQUIRED FEE' P�RMIT# LICENSE REQUIRED FEE P IT# LICENSE REQC UIRCD FEE PERMIT# '—�100 SF'A SS $200 ,,, �C'OMMO VIC $60 -�� —WHOLE3ALE $80 —RESID.KtTCHF,N $&0 —��—�y RETAIL SERVICE: � LICENSE REQUIRED FEL PERMIT# L2CENSE REQUIRED FEE PERMIT tt LICENSE REQUIRF,D FEE PERMIT# <SOsq.ft. $50 >25,OpOsq.f't $285 VENISING-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 �-- —TOBACCO $110 —��— NAME CHANGE: $15 AMOUNT AU�+ _ $ q O.C�Q *****PI.EASF.TURN OVER AND COMPLETE OTHER SIUE OF FORM***** ADMINISTRATION + Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmauth is now required ta hold issuance or renewal of any Iicensa or pennit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TIIE ATTACAEIt STATE WOI2KER'S CC?MPENSATION INSUItA1VCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND A'tTACHED Torvn of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: 'YES NO _ MOTELS ANA OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be lirnited to the temporary and shart term occupancy,ordinarily and customarily assocaated with motel and hatel 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 nol 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 residenoe or dwelling unit shall not be considered Lransient. Occupancy that is subject to the collection af Raom t}ccupancy 2;xcise,as defined in M.G.L. c. 54G or 834 CMIt 64G,as amended, shall generally be considered Transiant. POOLS POCiL OPENING:All swimming,wading and whirlpools whsch have been ciosed for the seasan must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspect'ton three (3) days prior to opening. PLEASE N4TE: People are NOT atlorved to sit in the pool area until the pool has bean inspected and opened. POOL WAT�R'1"ESTING: The water must be tested for pseudomonas,total colifor[ra and standard plate count by a State cettified lab, and submitted to the Heaith Departrnent three (3) days prior to opening, and quarterly thereafter. POflL CI.OSING: Every outcloor in graund swimming poal must be drained or cavered within seven(7)daas of closing. FQOD SERVIC� SEASONAL FOdD SERVICE OPENING: All faod service establishments must be inspected by the Health Department prior to opening. Please contact the Health Dcpartment to schedule the inspection three{3)days prior to apening. CATERING PLiLICY. Anyone who caters within the Town of Yatmouth must notify the Yarcraouth Health Department by filing the required Temparary Faod Service Applicatian farm 72 hours praar ta the c�tered event. Thesa forms can be obtained at the Health Deptaztment,or from the Town's website at www.varmouih.ma.us under Healtb Deparhnent, T)awnloadable Farms. 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 Department. Failure to do so will result in the suspension ar revocation of your Frozen Dessert Permit unrii the abave terms have been met. C}UTSIDE CAF�+S. Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health. —---- —- _ _ _- ---__ - -. . _ __.. --- _ _ _ _---__ -- OUTDOOR COOHING: Outdoor cooking,prepazation,or dispIay of any food product by a retail or foad service establishment is prohibited. NOTICE: Permits run annually from January 1 ta December 31. I'l'IS YOUR KE3k'ONSI�ILI'TY TO RETI.JRN THE COMPLETED REN�WAL APPLTCATION{S}AND REQUIR�3D FEE(S}BY DECEMBER 25,2d14. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO'CEL OR POOL (i.e., PAINTING, NEW EQLTIPMENT,ETC.}, MUST BE REPORTED T'4 ANLt APPRQVEi7 BY TIiE BOARD OF HEALT�-I PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A SIT� PI,��y,,�^�-- � DATE: /��-' �'--/l�__SIGNATURE: � � ��rT r1��& TIT�:E:��+�(�((�,�� i�2n, . Rev_ 11103I34 ' ' r `�� The Commonwealth ofMassachusetts Department oflndustrialAccidents Offace of Investigations I Congress Street, Suite Z00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le¢iblv Business/OrganizationName:��//�_��al�___y_�c�itC� Address:?� � P�EL15acot� � City/State/Zip: Phone#:hd�S Q Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail 2.� or part-time).* 6. ❑ RestauranUBaz/Eating Establishment I am a sole proprietor or partnership 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 aze 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.❑ Health Caze 4.❑ We aze a non-profit organization,stafFed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the sec[ion below showing the'v workers'compensatio¢policy infotma[ion. **If the co:porate officers have exempted themselves,but the corpora[ion has otha employees,a worlcecs'compensation policy is required and such an organization should check box#I. I am an employer that is providing wor X ri'c�ensation insurance jor my empinyees. Below is the policy infarmation. Insurance Company Name: Insurer's Address: City/State/Zip: - �cficy#or3eif-ins:�ie:�— -_ _ _ ___ — --- - �Bat�a--- - --- --- Attach a copy of the workers' compensation policy declarafion page(showing the policy number and expiration date). Failure to secure 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 forwazded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby cerh ,under thepains andpenalties ofperjury that the information provided above is true and correct. Sienature= /`//��(/JY�,O��_��- '� Date• /� �� `/L� .�.� .--- Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board oF Health 2. Building Department 3. City/'Pown Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia