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Home My WebLink AboutApplication and WC � � � TOWN OF YARMOUTH BOARD OF HEALTH E L`3''��G�O�lC�DD �� APPLICATION FOR LICENSE/�,�k � 2 39(� `� * Please complete form and attach all necess�do �_ t� ° n`�� be IS��711'4:t5 Failure to do so will result in the return of your apphcation ac �ALTH DEPT. ESTABLISHMENT NAME: Tu..�/ �u�C.+� /rl AaP/ TAX ID• LOCATION ADDRESS: /D�Y7 �ZT �� 5 yAsPmev/h' TEL.#: �,4� �76o-3Bea MAILING ADDRESS: s.4n'/� �5 .�Ba ✓x E-MAIL ADDRESS: ,g,t�ir�u 66 e�i Yr9-hho ��. OWNERNAME: r�LFF� /�sfvoP.PiI-/l'I • CORPORATION NAME (IF APPLICABLE): jou�iv Qu ie� /I/AAsP% i�v�' MANAGER'SNAME: �J/,Etr/�'J TEL.#: See9_360-30?3� MAILING ADDRESS: �s�-mf �S .�l3o vE - 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 f . __ __ — _ _ - - 1. 2 __ _ - Pool operators must list a minimum of two em ees currently certified in basic water safety dazd First Aid and Community Cardiopulmonary Resuscit 'on(CPR), having one certified employee o remises at all times. Please list the employees below and atta copies of their certifications to this form.T ealth Department will not use past years' records. You st provide new copies and maintain a t' at your place of business. 1. Z• 3. 4• FOOD PROT ION 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 H th Department will not use past years'records. You must provide new copies and maintain a file at y r establishment. 1. 2• PERSON IN CHARGE: Each food establishment must have east one Person In Charge (PIC) on site d ' g hours of operation. - - . . _-- - _- - _ _ 1. � -- - - ALLERGEN CERTIF ATIONS: All food service es ishments are required to have at least o 11-time employee who has Allergen certification, as defined in th tate Sanitary Code for Food Service E lishments, 105 CMR 590.009(G)(3)(a). Please attach copies of ce ' cation to this application. The Heal epartment will not use past years' records. You must provide new copies and maintain a file at you�establishment. 1. 2• HEIMLICH CERTIFICATIONS: All food service establishments h 25 seats or more must have at least one employee ned in the Heimlich ' Maneuver on the premises a times. Please list your employees trained in anti-cho ' g procedures below and ', attach copies of employe ertifications to this form. The Health Department w' ot use past years' records. , You must provide n copies and maintain a file at your place of busine . ' 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 . INN $55 CAMP $55 SWIMMINGPOOL$IlOea � LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea �. FOOD SERVICE: �� LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 � —RESID.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,OOOsq.ft. � $I50 6� —FROZENDESSERT $40 �TOBACCO $110 �3 NAMECHANGE: $15 AMOUNTDUE _ $ 26�.nn *****PLEASE TURN OVERAND COMPLETE OTHER SIDE OF FORM***** 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 Yarmouth 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 OCCUPANC'Y: For purposes of the limitauons of-Motel or Hotel use;Transient occupancy shaltbe limited to the temporary 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 shail 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 or ' 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 which 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 ailowed to sit in the pool area 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 Departrnent three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of , closing. __ FOOD SERVICE SEASONAL FOOD SERVICE OPENING: , 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 priar to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Deparhnent, 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 Boazd of Health. OUTDOOR COOHING: j Outdoor 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 RET'[.JRN 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.), NIiJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A SITE1 PLAN. DATE: I�- /6_ /.S SIGNATURE: PRINT NAME &TITLE: ^-';=�M .�C f�?/�R.�'/ /� �� ' � Rev. 1 I/03/14 ��, ~ ' � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite I00 Boston, MA 021I4-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anulicant Information Please Print Leeiblv Business/Organization Name: %.,usiv �isi['�' srl�taP� /oU t'_ Address: /o �' 7 — �P % a t� City/State/Zip: ,�' ,��//fi-�/rI o v/%' Phone #: �o�'_ 760 —�3�'00- Are you an employer? Check the appropriate bos: Business Type(required): 1.� I am a employer with employees(full and/ 5. ,�Retail or part-time).* __ 6. ❑ RestaurantBaz/Eating Establishment - — - -- - 2. 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] $• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.� Health Caze with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also 5ll out the section below showing the'u workers'compensation policy information. '*If the coiporate officecs have exempted themselves,but the corporabon fias other employees,a wodcets'compensation policy is required and such an orgauization should check box#I. I am an employer that is providing workers'compensation insurance for my empLoyees. Be[ow is the policy tnformation. Insurance Company Name: ,%�,�}�/��Q S • Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # ��l/.� — ��'J��Expiration Date: �� — /S — �._� Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration date). _ _Failur�tn��ute�ovetage as r�uir�$�der S,gction 25A of MGL c,152 can le__ad to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year 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 forwarded to the Office of Investigations of th DIA for insurance coverage verification. I do hereby certify, er the pains and pena[ties of perjury that the information provided above is true and correcx Si ature: � Date: �— /— Phone#: � /J/� .� ��L� �Od� O�cia!use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of I3ealth 2. Building Department 3.City/Town Clerk 4. Liceasing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia