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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH ��d�� i �� APPLICATION FOR LIC �-� MAY 1 1 2015 `� * Please complete form and attach all n : �oc�n�}; ec mber IS 2014. ! Failwe to do so will result in the return of your appli cation ac L P T. � ESTABLISHMENT NAME: TAX ID: � LOCATION ADDRESS• `?� TEL.#: �`3 7Qit� /Z1]'2- MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: "� CORPORATION NAME LIC L : � I MANAGER'S NAME: ' EL.#: oS ` �� MAILING ADDRESS: � S�' - i POOL CERTIFICATIONS: �� J,�'' I The pool supervisor must b L�rtified 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. I 1. 2. I Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid i and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. i 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. I � 1. 2• � 3. 4. i FOOD PROTECTION MANAGERS - CERTIFICATIONS: ' All food service establishments aze required to have at least o en�full-� 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. ;I 1. 2• � PERSON IN CI-IARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � l. Z � ALLERGEN CERTIFICATIONS: '� All food service establishments aze required to have at least one full-time employee who has Allergen certification, i as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach I 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 haue at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-chokmg procedures below and i 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. 2. 3. 4• RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# B $55 CAMP $55 —MOTEL $110 � SWIMMING POOL$I l0ea ODGE $55 � _TRA[LERPARK $105 _WHIRLPOOL $IlOea. 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 _��D.KITCHEN $80 RETAIL SERVICE: LICE OSS REQUIRED $BO PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � q >25,000 sq.ft. $285 VENDING-FOOD $25 =Q5,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ *G*k* PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*"*" / ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yannouth 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 5TATE WORI{ER'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 taaces 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 ofMotel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy,ordinazily 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 thirly(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 i dwelling unit sha11 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. i 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 allowed 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 standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. � POOL CLOSING: Every outdoar in ground swimming pool must be drained or covered within seven(7)days of i closing. I 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 Departxnent by filing the , required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ' obtained at the Health Department,or from the Town's website at www.�armouthma.us under Health Department, 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: ( 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 December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2014. � i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ! EQUIPMENT,ETC.), MLJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: SIGNATURE: PRINT NAME& TITLE: Rev. 11/03/14 '�, i ' � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations ' 1 Congress Street, Suite I00 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name: � v� Address: � � �E- `� City/State/Zip: Phone#: �b� %�/" `� /Z�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. ❑ RestaurantBaz/Eazing 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 employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organization,staffed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp.insurance req.] 12:�Other *Any applicant that checks box#1 mus[aLso fill out the section below showing their workers'compensation policy infojmation. *•If the corpoiate officexs have exempted themselves,bui ihe corporation has other employees,a workers'compensation poGcy is requ'ved�d such an o:gani�4on should check box#1. - � - � I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy informarion. 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(sLowing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penatties of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalries in the form of a STOP VJORK ORDER and a Sne 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 Investigations of the DIA for insurance coverage verification. I do hereby cen' ,u der 'ns and pen ' ofperjury that the information provfd� ve ' true and corred. Si ature: Date: '7 �l /�� Phone#: a� O /Z 2— Official use only. Do not write in this area,to be comp[eted 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.Liceusing Board 5: Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia