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Home My WebLink AboutApplication and WC� .� TOWN OF YARMOUTH BOARD OF HEALT ��0�'IL�DD � � � � APPLICATION FOR L�C'�N�� '�1 Nhl 1 3 2015 � �"' * Please complete form and attach a�I�tie do��ents b December I5. 2014. ' Failure to do so will result i `�hf e refurn of your appli tio�.DEPT. ! ESTABLISHMENT NAME: ' — TAX ID: LOCATION ADDRESS: �G-vLL oo TEL.#: /�6 MAILING ADDRESS: I GY� --M� E-MAIL ADDRESS: ` i C - M i .C6 OWNER NAME: CORPORATION NAME (IF APPI,ICABLE): ,�/,q MANAGER'S NAME: �,�t�4A �,,�5� TEL.#: ��/ 36�•oZg33 MAILING ADDRESS: /3�9 . AC�t1ifT'C A s�act�cm�f� c��G�� 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 minimum of two employees currently certified in basic water safety, standazd 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. 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 ce 'fication t this application. The Health Department will not use past years' records. i You mu t provide ew opies an maintain a file at your establishment. ', 1. ` 2. ', � PERSON IN CHA E: ' Each d establis nt must h ve at least one Person In Chazge (PIC) on site during hours of operation. 1. � 2. ALLERGEN CERI'IFICATIONS: 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 's ap lication. The Health Department will not use past years' records. You must provide ew copie main ain a�le at your estabGshment. 1. 2. MLICH CERT CATIONS: ' All food service e ablishments 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-choking procedures below and , 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 £le at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PfiRMIT# � - B&B- $55 CABIN $55 MOT'EL $110 � INN $55 CAMP $55 SWIMMINGPOOL$110ea. �, LODGE $55 TRAILER PARK $105 � WHIRLPOOL $110ea ��.. FOOD SERVICE: ��' L�CENSE REQUIRED FEE PF�RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# . �0-100 SEATS $125 -i�f S <<o�J —CONTINENTAL $35 NON-PROFIT $30 >l00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 ��. —RES[D.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 $I10 NAME CHANGE: � $l5 AMOUNT DUE _ $ U�-i (i l l � ****"PLEASE TURN OVER AND 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 dr p$trfilt`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 ofthe limitations of Motel or Hotel use,Transient occupancy shall be I 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 sha11 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 Departxnent prior to opening. Contact the Health Departxnent 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 I 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 thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. j 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. i CATERING POLICY: I Anyone who caters within the Town of Yannouth 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 obtatned at the Health Department,or from the Town's website at www.yarmouth.ma.us under Healttt 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 Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishxnent is prohibited. i�TtTTIC�:Perx�its�v�aunually framTanuac�1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN � THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)SY DECEMBER 15, 20.�1.- G ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BO OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE IRE A SI P AN. � DATE: �//��/�i SIGNATURE: , PRINT NAME & TITLE: � S 4�� Rev.11/03/14 � I � r � � The Commonwea[th ofMassachusetts � Department of Industrial Accidents Offace of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Legiblv Business/Organization Name: �,.,��c �Siv,�rld i�e . „D /�1 �'.re ,�-r �'fl'��d� Address:��(. l��ds�-��-< .Qi �2 co �.�R2�-S�j'�C �4 o z.�R � , City/State/Zip: p�LJ��f�/�- _�y��Lg� Phone #: �y„?�Sf�� 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. ❑ RestauranUBaz/EaYing 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] 8• ❑ Non-profit 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemp6on per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. inswance required]* ' 4.❑ We are a non-profit organization, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also 5ll out the sectio¢below showing their workecs'compensation policy infoimation. �� "If the coiporate officers have exempted themselves,but the coxporation has other employees,a workets'wmpensation policy is required and such an omoani>ation should check box#l. � '. I am an emp[oyer thai isproviding workers'compensation insurance for my employees. Be[ow is thepolicy information. ' Insurance Company Name: ;i 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 policy number and ezpiration 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 penaities 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 Investiga6ons of the DIA for insurance coverage verification. I do hereby c ' ,under t p s and enalties ofperjury that the information provided above is true and correct. i I Si ature: Date: ' I Phone#: ' Official use on[y. Do not write in this area,to be comp[eted by city or town officiaL i City or Town: Permit/License# '� i Issuing Authority(circle one): j i.Board of Health 2. Building Department 3. City/1'own Clerk 4. Licensing Board 5. Selectmen's Oftice � 6.Other Contact Person: Phone#: i www.mass.gov/dia j