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Home My WebLink AboutApplication and WC ��, � a � TOWN OF Yr1RMOUTFI BOARD OF HEALTH � , �;�J�D �� APPLICATION FOR LICENSE/PERMIT � ' � * Please complete form and attach a11 necessary� ecember 35 �1012. Failure to do so will result in the retum of your'a ' ati n pp�jtTH DEPT. ' S��az CEur�rL ESTABLISHMENT NAME: �G1� � U/ T ID: � �� LOCATION ADDRESS: !i TEL.#: . 4 MAILING ADDRESS: / ' OWNER NAME: ��l�D ��S CORPORATION NAME (IF APPLICABLE): /lL�' MANAGER'S NAME: v TEL.#: � MAILINGADDRESS: � �6IC �/ �� I�Y'JLf �� C�Z�P�o�1 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, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. 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 certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a Fle at your establishment. �. /.��'Q 7,�'S 2. �lr �'� i��'_S _ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. l��C� �/'�'1"x'S a. 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 all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. /ll�/ 2. 3. 4• RESTAURANT SEATING: TOTAL# L/ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' B&B $55 _CABIN $55 _MOTEL $55 INN $55 _CAMP $55 _SWIMMING POOL $80ea. LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �-100 SEATS $85 �.l.�f�'�—CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 —�FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ b'S� **"**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 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 taces 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 of Motel or Hotel use,Transient occupancy shall 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 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 ' 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 allowed to sit m the pooi 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 requued 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.yarmouthma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafrer,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 RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2012. 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 RE IRE A SITE PLAN. DATE: l SIGNATURE: � ��L� PRINT NAME & TITLE: `C� �j�� Rev. 10/09/12 � TheConimoniveallh ofMassachrrseds Departmein ojlndustrial Acciden�s � �J�'��: ._: Y4 - � �ce of Inves�igotions �'-�`� ; :�' 1 Congress Sdeel,Suite 100 '•';':_,r+=',;` Boston,Mrl 0211d-2017 '��•'` ivwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Generai Basinesses Aooticant Information Please Print Legiblv Business/Organization Name: , I�� (rU�� Address: City/StateJZip: , Y�] ��P //YtQ��Phone#: �� 7[-Z `�� Me yoo sa emplo�•er?CAeck the appropriate b�: Basioesa Type(reqaired): 1.❑ 1 am a employer with employees(full and/ S. ❑Retail 2.�part-time).• 6.,�RestaurmtBar/Eating EstabGshmmt am a sok proprietor arpertnaship md have uo 7, �Office and/or Sales(incL real estate,anto,etc.) employees work6yc for me in any capacuy. (No wo�cers'comp.iasurance required] $� ❑Nonprofit 3.❑ Ne are a coryoration and iu officers have exercised 9. ❑Euterminment their rig6t of exemption per c. 152,§1(4),and we have 10.❑Manufacturmg no employees. �1Vo workers' comp.iusurmce raryired]� 11.�Health Care 4.❑ W e are a non-profit orgmaation,staffed by volunteas, with no empbyees. (No workas'comp.insuiance req.] 13.�Other •pnY e�licmt that chedcs box dl mus[dso 611 ont 16e sectim beloa•s6ovvio8lhdr wwkcs'compensadm pdiq iofamation. s•If�he empmme offieas 6we a�ped themsdves.6nt t6e caporadm 6as a6a employees,a aorlm`cmpmsmim pdicy is rcquired�d wcL m mg�izsum s6ould chedcbox al. I�an ee�lage��eat is prmdGing r+orkeis'compensatloa lns4rance for�'empla�'ees. Below Ls tke�oll4v iq/brsiallon Insurance Company Name: Insurer's Address: CitylStale/Zip: Policy�orSdf-ins.Lic.# Expirau�Date: Attac4 a cop�-of the�rorkers' comp msatlon poUc�•deds�stlon page(s6on•ing tbe policc oum ber so d etp ir�tlon date} Failuie to secure coverage as�uired under Section 25A of MGL c. 152 can lead to the imposition of criminel penatdes of a fine up ro S1,500.00 and/or one-year imprisonmenL as well as civil peualties in the form of a STOP WORK ORDER mmd a 5ne ofup ro 5250.00 a day ageinst the violator. Be advised that a copy of this statemmt may be foxwatded to the Office of Investigations of the DIA forinsu�ance coverage v�mtion. I do karbp cer({(p,�aA tke poins and enalSu ojpery'ury lhat tlre iq/'orniatlan prorbed above is dru and com,ct � n Signatuce: --- - -Q �-- - — - Dffie: ---H-��—_ . _ P�n��: ��y 7 �f Cl _ — -- -- O,�/9clo[rse on{p. Do not wrlte!n tb6 arta,ro be completed br cfty or bwn o„Q7ela1 Cin•orTown: yA�MOvil� Permte/Lic�seil o cleooe): .Hoard otHealtp BoOding Deparlumt 3.Ciq•/foa•o Clerk 4.Ltc��u=Board 5.SdaOnm's Olnce 6. Conhct Peraoo: Pbone q: �(3 3QQ�}.3v�� IC �2�[� wsvamau.gw��a