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Home My WebLink AboutApplication and WC , , a�G� � � � TOWN OF YARMOUTH BOARD OF HEALTH DEC Z 3 ZO14 , APPLICATION FOR LICENSEy ,r, - 2 `" * Please complete form and attach all neces '"' ` �'�'y� e er DEPT. "� Failure to do so will result in the ret�:of}�wr:;a�p�a�o ac et. ESTABLISHMENT NAME: -2.t� � TAX ID: LOCATIONADDRESS•�� s� S'; I,U �n,artMOfl TEL#•50�'77S� ��, MAILING ADDRESS: ct�v✓1 E-MAIL ADDRESS: OWNERNAME: i � i� � CORPORATION NAME (IF LICA LE): � i� MANAGER'S NAME: Vo i TEL.#: 3- oZ, MAILING ADDRESS: � . 8� 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. CQitcW I�P S ��CI�vL�� 2. T D d��G�l. i`�A�vt� 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. �0 � �[� �Zfl��f�J� 2. 3. �i �P � T— 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 p ov►de new copies and maintain a �le at your establishment. 1. V 0 t,�C�- ��l �v�1�--�/Gc�✓J r�(,�-x.t�S 2. PERSON IN CHARGE: Each food establishment must have at least one P son In Charge (PIC) on site during hours of operation. _ 1. V c�C;C X�= �J i�,��-t�� _ 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-chokuig 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 mainta�n a ►le at your place of business. 1. �DGI.Q�- �l �(�1 � ,�� 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 $110 0`F� —INN $55 CAMP $55 �SWIMMINGPOOL$IlOea. I� G C�`J LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �S��7 —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 (,�`f _WHOLESALE $80 — —RESID.HITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq ft. $285 _TOBACCO FOOD$$10 _Q5,000 sq.ft. $150 —FROZEN DESSERT $40 NAME CHANGE: $15 AMOUNT DUE _ $ �2 S-00 � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM ..... ��d �y yo-c�z'� �l�.-�-t3�3o ��Z�'�l� ." ADMINISTRATION Under Chaptet 152, Section 25C, Subsection 6,the Town of Yarmou#h is now required to hald issuance ar renewal of any license or perniit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WOI2K�R'S COMPENSATION INSURANCE AFP+IDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED QR WOR.KER'S C;OMP. APFIDAVIT SIGNED AND ATTACH�D Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. 1'LEASE CH�CK APPROPRIATELY IF PAID: YES � NO M4TELS AND UTHER LOUGI1vG ESTABI.ISHMENTS TRANSIENT OCCUPANCY: Far purposes of tne Iimitations of iUioteI or Hotel use,Transient occupancy shall be lirnited to the temparary and short term occupancy,ordinarily and customarily assaciated with mvtel and hotel use. Transient occapants tnust have axid be able to demonstrate 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 aggegate of not more than ninety{9d)days within any six{6}manth period. Use of a guest unit as a residance or dwelling unit shall not be oonsidered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or &30 CMR 64G, as amended, shall generally be considered Transient. POOLS POUL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule t�►e inspecYion three(3} days prior to opening. PLEASE NOTE: People aze NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER'CESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified 1ab, and submitted to the Health Department three (3) days prior ta opening, and quarterly thereafter. POOL CLOSING: Every outdoar in ground swimming pool must be drained or covered wiihin seven(7)days of clasing. F'OOA SERVICE SEASONAL FOOD SERVICE 4PENING: All faod service establishments must ba inspected by the Health Departrnent prior to opening. 1']ease contact the Health Department to schedule the inspection three (3) days pzior to apening. CATERING POLICY: Anyone who oatars within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temparary Faod Service Application forna 72 hours prior to the catered event. These forms can be obtained at the Health I}epartment,or from the Tou�n's website at www.vannauth.ma.us undar Health Department, Dowriloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a Stata certified lab prior to opening and monthly thereafter,with sampte results submitted to the Health Department. Failure to do sa will result in the suspension ar revocation af yaur Frazen Dessert Permit untiI the above terms have been met. OUTSIDE CAFL�`S: Outside cafes(i.e.,outdoar seating with waiteriwaitress service),must have prior apprnval from the Board of Hea1#h. OUTDOOR COOKIIYG: Qut�t�or cooking,preparation,ar display of any food product by a retail or faod service establishment is prphibited. NOTICE: Permits run annually from January t to December 31. IT IS YOUR ItESPQNSIBILITY TQ RETLTRN THE COMPLETED RENEWAL APPLICATION(S) AND RI:QCJIRED FEE(S) BY DECEMBER 15, 2014. ALL RENQVATIONS TO ANY FOQD �STABLISHMENT, MOTEL OR POQL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE RBPORTED 1'O AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMEAtT. RENOVATIONS Mt�Y REQUIRE A ITF,PLAN. DATE: i � ,.� I�SIGNt#TtJRE: PRINT NAME&TT1 LE:�� .. � �.i�vosna � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite I00 Boston, MA 02114-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le¢iblv Business/Organization Name: ��P�t,�I��Y �V� �—� Address: � �`j �� 7�� City/State/Zip: Vi/l Phone#: 5�-77 S�3Z z Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time�.* __ _ _ 6. ❑ Restaurant7Baz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required� $• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.Q Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Care 4.❑ We aze a non-profit organizarion,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the sec6on below showing the'v worke:s'compensation policy infotmafion. "If the cocporete officers have exemp[ed themselves,but the corporation has other employees,a workers'compensarion policy is requ'ved aud such an organization should check box#1. . I am an employer that is providing workers'�o�(p�ensahon insurance for my employees. Below is the policy informntion. Insurance Company Name:_�Y�JLX.(l� Insurer's Address: � ('� �j a� �'J��j y'� City/State/Zip: �v�`I-c7(/� � /V � � �.�/�� Policy#or Self-ins. Lic. #�( [ '� Z��'1"�3 Expiration Date: Z-O Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Fai_I,ure to secure coverage as required under Section 25A of MGL_c. 152 can lead to the imposition of criminal_penalries 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesugations of the DIA for insurance coverage verificarion. I do hereby certify,� id :e pains and penalties ofperjury that the infosmation provided above is true and correct. Sipnahue: Date• � 7�1�91�'—l' Phone#: -�i�$ ' 7 7 � —(J,�j Z Officia[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