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Home My WebLink AboutApplication and WC p . BUCK.YS •. � TOWN OF YARMOUTH BOARD, TI� a� �� APPLICATION FOR LICENSE/P� �j ' j 1��.�j� <� ��`�C�D �. '"' ��-'� D` . �` * Please complete form and attach all necessar}��doc e s y ece ber 2 Zo'��J Failure to do so will result in the return of your application p ket. � ESTABLISHMENT NAME: � TAX ID: - ,� LOCA'I'IONADDRESS:�B� �,�o,J�iS,C�rv>7 �P� • TEL.#: �a.9...535!- .$e(/ MAILING ADDRESS: tt1L�'�T �..�2inn c�i if rn�1- �i a26 7'�� E-MAIL ADDRESS: OWNERNAME: A.IE�/�'/ /�N�/RRAM CORPORATION NAME (IF APPLICABLE): �tXirlu ,i�C' - MANAGER'S NAME: ��LEF/�'� ' TEL.#: _g�� 36;n 3�2 3� MAILINGADDRESS: slfnZF f�S �6eYf 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 certificati n to this form. - - - _ __ 1. . 2. - _ _ _ ___ Pool operators must list a minimum of two ployees currently certified in basic water s ty, standazd First Aid and Community Cardiopulmonary Resu tation (CPR), having one certified employe on premises at all times. Please list the employees below and a h copies of their certifications to this form. e Health Department will not use past years' records. You ust provide new copies and maintain a Ti at your place of business. 1. 2• 3. 4. FOOD PROTECTI MANAGERS - CERTIFICATIONS: All food service stablishxnents 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 �le at your establishment. 1. 2• PERSON IN CHARGE: Each food establishment must have at le t one Person In Chazge (PIC) on site during hows of o ration. L _ _ - _ _ _ _ . 2. ALLERGEN CERTIFICATI S: All food service establishm ts aze required to have at least one full-time employee w has Allergen certification, as defined in the State S tary Code for Food Service Establishments, 105 CMR 0.009(G)(3)(a). Please attach copies of certification this application. The Health Department will not past years' records. You must provide new copie and maintain a �le 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. P ase list your employees trained in anti-choking procedures below and attach copies of employee certificatio o this form. The Health Deparhnent will not use pa e rs' records. You must provide new copies an aintain 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# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 i INN $55 CAMP $55 SWIMMINGPOOL$IlOea �'� _LODGE $55 =TRAILERPARK $105 _WHIRLPOOL $ll0ea. � FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �QS,OOOsq.ft. $150 �"f =FROZENDESSERT $40 �TOBACCO $110 �,jZ xaME c�NCE: $is AMOUNT DUE _ $ 2,�o. � , r,, a�. c�: � �,�n; � *****PLEASE TURN OVER AND COMPLETE OTF��pR Y�ORIy�"'"� i �..--�—"__'.__.�� i W � ADMINISTRATION • Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO MOTELS AND OTHER LODGING ESTABLISHMENTS '� TRANSIENT OCCUPANCY: For purposes of the limitations of Motel ar Hotel use,Transient occupancy shall be limited to the temparary and short 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 occupancy shall generally refer to continuous occupancy of not 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 residence ar dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools wluch have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereaftez POOL CLOSING: Every outdoar in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: I All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.yarmouthma.us under Health Departxnent, Downloadable 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 Department. Failure to do so will result 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),must have prior approval from the Board of Health. OUTDOOR COOHING: i Outdoar cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RB UIRE A SITE PLAN. DATE: /�2/— /S SIGNATURE: �—" PRINT NAME &TITLE:��`''�� OGv�/T� Rev. 11/03/14 t � The Commonwealth ofMassachusetts ' Department oflndustrial Acctdents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaplicant Information Please Print Legiblv Business/Organization Name: ,e�!/r�� /��i^ ,f.� 69� �U�� _> Address: , �,� — ��UF 1'�is��-�-_, � �9� City/State/Zip: t(J�,.S l ` G'��/r! cl% Phone #: ��— ,.$3�j'_ j'D 6� Are you an employer?Check the appropriate box: Busin ss Type(required): 1.❑ I am a employer with employees (fiill and/ 5. �Retail or part-rime).* _ 6. ❑ RestauranUBaz/Eating 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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10.❑ Manufacturing no empioyees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organizarion,staffed by volunteers, I 1.0 Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant thaf checks box#1 must also fill out the secdon below showuig the'v workers'compensation policy infotmazion. **If the coxporate officers have exempted themselves,but the corporabon has other employees,a workers'compensaaon policy is required md such an organization should check box#I. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: � City/State/Zip: Policy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the poGcy number and ezpiration date). _ FailurQ to secut�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 fonvarded to the Office of Invesrigations of the DIA for insurance coverage verificarion. I do hereby cenf nder the pains and penalties ofperjury that the information provided above is due and correct. Si ature: � Date: � — /— /�— Phone#: �/)� r-- S� �Y'— /�� Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Liceasing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia