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Home My WebLink AboutApplication and WCI .d TO O�I'A�RMO TH BOARD OF H TH � �� l �� 'S � � APP IC�q�01PBI��LI E I ' i5 � � * Please comp te all n s � t�y�ecember IS 2014., g�-�-l. Failure e urn o your applicaUon pac et. ESTABLISHMENT NAME: T ID: LOCATION ADDRESS: � �/' �� z.+� 17tQu�� TEL.#: .5"08 3be2 -.33f�b MAILING ADDRESS: o? � /' a � .0 L . t ,� „�.�,.,, 5,-A. �Pn.�� ll� vz��S E-MAIL ADDRESS: ' � ' • C-D OWNER NAME: CORPORATIONNAME APPLICABLE): 1��>u=e-� �- l-�ors-v�,`�L.�r4�a-�Z5 �-�-L'- MANAGER'SNAME: �Mca��-e� C�ce.lurl� TEL.#: �ZJ6 �3(o�-3�i��o MAILING ADDRESS: �' C��7 Q�_ cz.o azr�e-� POOL CERTIFICATIONS: The pool supervisor must be certi£ed as a Pool Operator,as required by State law. Please list the designated iPool Operator(s) and attach a copy of the certification to this form. I 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 wi11 ! not use past years' records. You must prov�de 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. I Please attach copies certi ation to this application. The Health Department will not use past years'records. ' You mu t provid n w c es and maintain a file at your establishment. i � 1. . _ � 2. �j�, PERSON iCHA GE: ' Each food establishment must have at least one Person In Chazge(PIC) on site during hows of operation. 1_ 2. ALLERGEN CERTIFICATIONS: ,J All food service establishments are required to haue 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' recards. You must provide new copies and maintain a file at your establishment. , 1.Ck%u7czcA�a-��-�v��F"�ci.�: l 4Ju'�� l��-.�/I�'�5� �/Zc� (�IUi�Gc� . ! d�a— ,8�,a�1 inz � ANE'G � � � 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 a11 times. Please list your employees trained in anti-chokmg 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 file at your place of business. I 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 $ll0 — $55 S W IMMING POOL$1 l0ea _LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQ UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $l25 _WNTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 �. RETAIL SERVICE: �RESID.KITCHEN $80 LICENSEq REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _Q5,000 sq.ft. $I�50 �Z5,000 sq ft. $285 VENDING-FOOD $25 —FROZENDESSERT $40 _TOBACCO $ll0 � NAME CHANGE: $1S . AMOUNT DUE _ $_CJO • OO � "****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM � .��«x � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar 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 WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: � yE3� NO � MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel ar Hotel use,Transient occupancy shall be limited to the temparary and short term occupancy,ordinazily and customazily associated with motel and hotel use. Transient occupants must have and be able to demonsuate 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 I 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, sha11 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 aze 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 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. ' FOOD SERVICE SEA50NAL 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 prior to the catered event. These forms can be obtained at the Health Deparhnent,or from the Town's website at www.varmouth.ma.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 ofHealth. i 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 I THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER I5, 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 REQUIRE A S�I.TE LAN. � DATE: Jrl� �� SIGNATURE: ! - pRINT NAME &TITLE: � ��/� (�r ��,La,�6'/�-�� Rev. 11/03/14 / I ' � � The Commonwealth ofMassachusetts Department of Industrial Accidents Offzce oflnvestigations 1 Congress Street, Suite I00 l /'��a Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Business/Organization Name: �� '�Y��Q�C �� s��D� Address: ��l�"i��/�G�-� �n��a,� `�✓?,Grn n�p�-�— ��-i City/State/Zip: �_. /�7� 7,� Phone #:��^� ��7- ,�� lv Are you an employer?Check the appropriate boz: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant7Bar/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 are 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]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.� Other *Any applicant that checks box#1 must also fill out the section below showing the'v workers'compensatioa policy infocmation. **If the coipomte o�cers have exempted themselves,bu[the corporatlon has other employees,a worke�s'compensarion policy is required and such an organization should checkbox#1. I am an employer that is providing workers'compensation insurance jor my emp[oyees. Below is the policy injormation. 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 policy number and eapiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a fine up to $I,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 forwazded to the Office of Invesrigations of the DIA for insurance coverage verification. I do hereby ify, nder the p s and penalties ofperjury that the information provided above is true and correct. � Si ature: Date: d Phone#: � Official 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 HealtL 2. Building Department 3. City/To_ Clerk 4.Licensing Board 5. Selectmen's Office '�^�;� 11� 6. Other �'^�`�� :a,�; Contact Person: — Phone#: www.mass.gov/dia