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Home My WebLink AboutApplication and WC � £ G3C�G��`IC�D � � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PE I 20c1�5� } JAN 0 6 2015 �;: �"" * Please complete form and attach all necessarg��n�by Dec er 15 2014. Failure to do so will result in the retu�af}uwr.applieat�osi'pac et. HEALTH DEPT. ESTABLISHMENT NAME: � u� TAX ID: LOCATION ADDRESS: TEL.#: MAILING ADDRESS: �' '' " E-MAILADDRESS: o •Go OWNER NAME: f�i zabe}�. G�I�r�4W'G` CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �o.w+e q,s awl9LY TEL.#: MAILING ADDRESS: 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 minunum 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 the�r 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 �le at your establishment. 1. �i�=a�A2'�.�U�.�Li»�a�, 2. P�RSOi�i�:V-ei#A�frE: - - __ _ _. _ __ _— . _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �I Z.e.� ��V�� 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 Tile at your establishment. 1. �-!1Af�-�'�,��LLWiGIV'U�. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one amployee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Departmeat will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. Z. 3. 4. RESTAURANT SEATING: TOTAL # `�"a ^ �' .� , OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 ❑VIJ $55 CAMP $55 SWIMMINGPOOL$110ea LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 —CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 � _ — SRESID.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 AMOLTNT DUE _ $ S6-CY} *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***"* � ADMINISTRATIQN Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yarrnauth is now required tp hold issuance ar renewal a£any license or permit to operate a business if a person or company daes not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATIOPt INSURANCE AFFIDAVIT MUST 8E COMPLETED AND SI(GNED, OIi CEFtT. dF INSURAZv�CE ATTACHGD OR WOR.KER'S COMP. AFFIDAVIT SIGNED AND AT`TACHED� Town of Xazmouth taxes and liens must be paid prior to renewal or issuance of yonr permits. PLEASE CHECK APPROPRIATELY IF PAID: ` YES- V — ��— _ MOTELS ANA OTHER LODGING ESTABLISHMENTS TRAN5IENT QCCIIPANCY: For purposes oPthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient accupancy shall generally refer tu continuous occupancy of not more than thirty(30)days,and an aggregate of not more than nrnety(90)days within any six(6)month peri,od. Use of a guest unit as a residence or dwelling unit shall not be cansidered transient. Oceupancy that is suhject to the collection of Raom Occupancy Excise,as defined in M.G.L. c. 64G ar 834 CMl2 64G, as amended,shall generally be considered Transient. POOLS POOL OPENING:All swiinrning,wading and whirlpools which have been closed for the season rnnst be inspected by the Health Department priar to opening. Conkact the E3ealth Departrnent to schedule the inspection three(3) days prior fo opening. PLEASE NflTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. PO4L WATER 1"ESTING; The water must be tested for pseudomonas,tota!coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterty thereafter. PQOL CLOSIAFG: Evary outdoor in grow�d swirnmang pool must be drained ar covared urithin seven(7)days Qf closing. FOOD SF,RVIC� SEASONAL FOOD SERVICE OPENING: All food service estabIishments must be inspected by the Health Departmeni prior ta opening. Please contact tha Health Department ta schedule the inspection Yhree(3) days prior to opening. CATERIIYG PQLiCY: Anyone who caters within the Town of Yaimouth must notify the Yarmouth Health Department by filing the reqwred Temparazy Food Service Application form 72 hours priar Ta the catered event. These forms can be obtained at the Health Depttrtment,or fram the Town's website at www.varmouth.rna.us under Health Depar�ment, Downloadable Farms. FROZEN D�SSERTS: Frozen desserts must be tested by a 3tate cerCified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocarion of your Frozen Dessert Permit until the abaae terms have been meC. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. _ _ . _ _ _- - _ __ _ OUTDOOR COCIHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to Dacember 31. IT IS XOLTR 12E3PONSIBILI'1'Y 1'O RE�I't..iRN THE CdMPLETED REIVEWAL APPLICATIdN(S)AND REQUIRF,D FEE(S}BX DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN7'ING, NEW EQUIPMENT, ETC.},MUST BE ItEPC?RTBI}TO AND APPROVED BY THE BOARI}C}F HBALTH PitIt}R TO CQMMENCEMENT. RENOVATIONS MAY REQUIRE 5ITE PLAN. DATE: 1 L 7.C7i S SIGNATU . � a„�,,yQ�.. PRINT NAME& TITLE: �2veJaC{-(.t, ��7� , Rev. f]143114 � � � The Commonwealth ofMassachusetts Department oflndustrial Accidents � Office of Investigations I Congress Street, Suite l00 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name:�(.p��`ti�(�j yy�u�� 7 p Address:�{--�Cj,L�n(�c1.-�S �i1�1(��. City/State/Zip: G{Y Phone #:,SC�--(o,S`3--S3OG� Are you an employer? Check the appropriate bos: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-fime).* 6. ❑ RestauranUBaz/Eating Establishment 2.g] I am a sole proprietor or parmership 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] 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]* 4.❑ We aze a non-profit organization,staffed by volunteers, 1�1.❑,� Health Caze �� I . � with no employees. [No workers' comp. insurance req.] 12.� Other (ZQ5)LY9YLllta( L}t(J�I�I.. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infoimation. "'If The co�porate officers have exempted themselves,but ihe corporation has other employees,a wockers'compensation policy is requ'ved and such an organization should checic box#1. I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the po[icy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or�elf=ms:Lic.�— ------ --- — _ --- - - —E�cpiration�ate:-_ _-- -___---__-- -- Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration 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 Invesfigations of the DIA for insurance coverage verification. I do hereby cenify,under the pains and penaUies of perjury that the information provided above is true and correct Si ature. Date: �u Phone#: �g— — 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