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Home My WebLink AboutApplication and WC ` �� t�`tLS�I'��silcUL� (LEi ��ic � TOWN OF YARMOUTH BOARD OF HF�A� JU�� O 9 20�� APPLICATION FOR LICE�� g w ... � * Please complete form and attach all �e s e� ece � Failure to do so will result in the return of your applicati . ESTABLISHMENT NAME: �F S 5U TAX ID: - LOCATION ADDRESS: Z I(� I � TEL.#: Sb9-3 -d 1 ZJ MAILING ADDRESS: .O E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): �/A R-I✓I ISLLI N �i �IS L SI1� MANAGER'S NAME: GJI�iVEN I�I�UCI � TEL.#: Mau,rrrG aDD�ss: Sio TI�D��Y�:I LL� R I�Yi W. Y Ft A It 1�f �— �—� - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as quired by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to thi rm. -- 1 ---- -- ___ __._ . __ 2 ___ Pool operators must list a minimum of two e oyees cunently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resusc' ion (CPR), having one certified employee on premises at all times. Please list the employees below and a copies of their certifications to this form.The Health Department will not use past years' records. Y� st provide new copies and maintain a file at your place of business. 1. � 2. 3. /� 4. , FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments 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 file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. __...1_�`�� . ."f�. 2. ALLERGEN CERTIFICATIONS: 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 this application. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your establishment. �. ti�Tlltil l�A�aCI�Z, _2. HEIMLICH CERTIFICATIONS: All food service establisl�ments 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 fo The Health Department will not use past years' records. You must provide new copies and maint ' a file at your place of business. 1. 2. 3. 4. RESTAURANT S ING: TOTAL# --- _- _—_-- - - _ _ -O�F�'��5�Ol*FLi� __ _ _ - -- .__— _ _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P I 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 REQU(RED FEE PERMIT# <50 sq ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 Q5,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $]10 NAME CHANGE: $15 AMOUNT DUE _ $ 3 0.DO � *****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 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 �ENT-0CGUPAlYGY: ForpurposesofthelimitatiQnsofMotelorHoteL�,-Tr_a�.o�cuL,�c3+�-� 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 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, sha11 generally be considered Transient. POOLS YOOL 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 Departrnent 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 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 prior 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 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,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 REQUIRE A SITE PLAN. DATE: I5 SIGNATURE: �n`r 1� �\ ) V V�t�w� � �-y� PRINT NAME & TITLE: Ifl/�IVI f7 Y �iI1L 111.C.� WI�G�1� Rev. 11/03/14 r � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite 100 Boston, MA 02I14-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: 7��M�I I�"��i�N�S �ri� ��✓�1`�/r11/L_ �� Address: Y ��• �d/� City/State/Zip: �1�v V1, �UY I one#: JO U ' �'l� � �Z�`►' �VVi,Y{�TrEC�) 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. ❑ RestaurantBaz/Eating Esffiblishment 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 are a corporarion and its officers have exercised 9. ❑ Entertauunent their right of exemption per c. 152, §1(4),and we have 10.� Manufacturing 4„�no employees. [No workers' comp. insurance required]* We aze a non-profit organizarion, stafFed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensatioa policy information. **If the co�porate officers have exea¢p[ed themselves,but the corporation has other employees,a wotkecs'compensation policy is=equued and such an organi�ation should check box#L � - �" - - -�- � - I am an employer that is providin worke s'co nsaf n ins ance for my employees. Below is the policy injormation. Insurance Company Name: Insurer's Address: O City/State/Zip: �v�� I V� U'✓�� Policy#or Self-ins. Lic. # W�V I 1. iT��'f��Q I Expirafion Date: �� Attach a copy of the workers' compensation policy declaradon page(showing the policy nnmber nd eapiraHon date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a me up to ,� . an or one-year im nson . 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 verificarion. I do hereby certify,under the pai s and pena[Ses ofperjury that the informafion provided above is true and corred Si�nature: �M/��N U1L1il.L Date: U' � � �� Phone#: 'J�/U ' "J /i Officia[use on[y. Do not w�ite in thu area,to be comp[eted by city or town officiaL City or Town: Permit/License# Issuing Authority(cirde one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia