The URL can be used to link to this page

Home My WebLink AboutApplication and WC , • - SP�e�sr� � � � TOWN OF YARMOUTH BOARD OF HEALTH �'�c-cvy� �, APPLICATION FOR LICEN T , ° ,. `� * Please complete form and attach all nec "� � � mber IS�20t4�.'� Failure to do so will result in the r ` o ' ` a i�a ion ac t.' _ ESTABLISHMENTNAME: sr n;l,_� pa,-; �t, r.ife Center TAXID: LOCATIONADDRESS: 25 Barbara Street TEL.#: 508-398-2248 MAILING ADDRESS: 5 Barbara Street South Yarmouth. MA 02664 E-MAILADDRESS: stqiusxoffice(�comcast_net OWNERNAME: Most ReV. Edgar DaCunha � Sishnn nf Fall Rivar CORPORATIONNAME (IFAPPLICABLE):Roman Catholic Bishon nf Fall Rivar MANAGER'S NAME: very Rev_ GeorqP C'_ Ral l anni t TEL.#: MAILINGADDRESS: s Rarhara Straat Rnnth varmouth, MA 02664 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. 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 file at your establishment. 1. reor�s &'� nn Z. �-7fPUP. �,�2.Oi.415�C.� PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. .. _ _-_-r..��6�h'i�nn___ _-__ __ _.__. _._... _ ..---7 --:�i�ti�� Ys ��izi��ii--r_.____ 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. �eorGe �t�tV� 2. �h.v��2 5o7_k-��5�� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or mare must have at least one employee trained in the Hennlich 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. 5� �S� 2.__ Joavi, 62,e1S 3. L a b� i7-�-a 4•�1 l nl nP RESTAURANT SEATING: TOTAL# 5. GPorr�e F, N N -- ___ _� ---- _�r�tc��s� orv� __ — — -- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 IMV $55 CAMP $55 SWIMMINGPOOL$110ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $il0ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PE�RMIT# , �100 SEATS $200 —CONTINENTAL $35 �NON-PROFIT $30 ir;_�� — _COMMON VIC. $60 WFIOLESALE $80 RETAIL SERVICE: � —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sy.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $ll0 NAMECAANGE: $15 AMOUNTDUE _ $ 30.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRA.TION Under Chapter 152,Sectioti 25C, Subsection 6,the Town of Yarmouth is now required ta hold issuance or renewal of any license or permit to operate a business i£a person or company does not have a Certificate of Worker's Compensation Insuranca. THE ATTACTiED S'['ATE WOI2KER'S CpMPENSATION INSUItANCE AFFIDAViT MUST 13E COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WtJRTS.ER's CdMP. AFFIDAVI`I SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPI2IATELY IF PAID: YES NO_� f�� MOTELS AND OTHF.R LODGING E5TABLTSHMENTS TRAN5IEN'P OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 be Iimited to the temporary and shoct term nccupancy,ordinarily and customarily associated with motel and hotel use. Txansient occupants must have and be abie to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy o£not rnore than thirry(30)days,and an aggregate of not more than ninety(90)days within any six(6)month periad. tJse of a guest unit as a residence or dwelling unit shall not be considered transient. Occupaney that is subject ta the caliection of Room Oceupancy Excise, as defined in M.G.I.. a 64G or 830 CMR 64G, as amended, shall �;enerally be cansidered Transient. POOLS POt1L O PENING:All swimming,wading and whiripaols which have been clased for the season rnust be inspected by the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to apening. PLEASE NC}T`E.: People aze NQ't' allowed to sit in the paai area until the poai has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliforrn and standard plate count by a State ceztifed lab, and submitted to the Health Departrnent three {3} days priar to opening, and quarkerly thereafter. PC}OL CLOSING: Every autdaar in ground swirnming pool musC be drained ar coverad within seven{7)days of closing. -- ____ FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establ3shments must be inspected by Yhe Fiealth Department prior ta opening. Please cantact the Health Departrnen[to schedule the inspection three (3) days prior to opening. CA�'ERiNG POLICY: Anyane who caters within the Town o£Yarmouth must notify the Yarmouth Health Department by filing the required T'empaary Foad Service Applicatian form 72 haurs prior to the catered event. These forms can be obtained at the Health Deparhnent,or fram the Tnwn's website at www.yarmouth.ma.us under Health Department, Dawnloadable 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 Departrnent. Failure to do so will resnit 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),mnst have prior approval from the Boazd of Health. OUTDOOR COCIKING: nutdoor cooking,preparation,<7r display of any faod produet by a retail or food service establishment 3s prohibited. NOTICE: Permits run annually frorn 7anuary 1 to December 31. IT I3 YO[IR RESPONSIIiIL1TY TQ RET LTRN `1'HE COMPLETED RENEWAL APPLICATION(S}ANI3 REQUIRED FEE(S}BX DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOdD ESTA$I,ISHMENT, MOTEL dR PO�L (i.e., PAINTING, NEW EQUIPMENT, ETC.},MUST BE REPORTED TO AND APPROVEI?BX THE$QAItD OF ITEALTH PRIOR TO CQMMENCEMENT. RENOVATIONS MAY REQUIKE A SITE PLAN, ]7ATE: " �3 h rs __SIGNATURE: �t � (��3211kSt�w.r� PRINT NAME& Tl"TLE: � �7�c�t2C� � 31t'zt�u o<i P,ryS7�� Rev. i1/63t14 . � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite I00 Boston, MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name:_�-�- N��'i�,� �( (��1�Y�� Address: J� �V' �ct,�a. S{Y2e� c;z�c� City/State/Zip: �'u,fh G(4'VYL�U� �1�1d`} Phone #: ��0 �� 3�$� ZL�'$� Are you an employer? Check th appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail _ _ or art-rime .* 6. ❑ Restaurant7BazBating Establishment - - - ---- - - - -- -- —-- - --_ _ __ — -- --- _ 2. I am a sole proprietor or partnership and have no �, � Office 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 corporafion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing 4.[�no employees. [No workers' comp. insurance required]* 11.❑ Health Caze We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' camp. insurance req.] 12.[�Other (�LU'1C�1 *Any applicant that checks box#1 must also fill out the section below showing their workexs'compensation policy informaiion. "If the cocporate officers k�ave exemp[ed themselves,but the wtporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Be[ow is ihe policy informatiore. Insurance Company Name: �} (1 i� ZNI�'P rVl OLf7 d V12.� I�iP1,U � l� ��Q61� Insurer's Address: �L�`L �� i �.� Vt Y�� f� . Ciry/State/Zip:�,�, I� I �e i^ �/�,�} OZ�Z� Policy# or Self-ins. Lic. # i.w��U Z�"oD gOC lol��I�,�C i�{A� Expiration Date: D`I !u L f�U l 5 Attach a copy of the workers' compensation policy declarakon page(showing the policy number and espiration date). Failure to secure coverage as required under Section 25A of MGL a 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 cro�Tpen�es iri the�orm of a ST6P WOKiC GAi)Eff an3a�ine - of up to $250.00 a day against the violator. Be advised that a copy of this statement may be fonvazded to the Office of Investigations of the DIA for insurance coverage verificarion. I do hereby cenify,under the pains and penalties ojperjury that the information provided above is true and correct S�ature• � �' �.�2..b.� Date `7`/(3l ad rs Phone#: .�a�-3�i d'� a ?�{ � � Ojficial 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/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia