HomeMy WebLinkAboutApplications and WCI � - � � TOWN OF YARMOUTH BOARD OF HEALTH `�-j��F�
�� APPLICATION FOR LICENSE� IT ��4 , ���, �5 LG13
* Please complete form and attach all nec�s qcuments by i�ember 13 2013.
Failure to do so will result in the returri of your applicati p�dBEA.TH DEPT.
� .._ �. .
ESTABLISHMENT NAME: P I4�� �' i M�1S TAX ID:
LOCATION ADDRESS: 17 �h j Qdnd Q�i✓c TEL.#: S�8— 7!0 -- �-3 oJ
MarL,�rrG aDD�ss: Js� Basd-0h PaS� ttd , p h a 3s4 � S�d 6��y �,,h o i �� c
E-MAILADDREss: jr� su 3'� d�cditcyta. nr�-
OWNERNAME: W 6 � �5C•
CORPORATION NAME (IF APPLICABLE):�� "rS C .
MANAGER'S NAME: �F i�-f /S�S�� � TEL.#:,�dR� `l6 0� 2.7ud
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool
Operator(s) and attach a copy of the certificafion 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),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 bf business.
l. 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 Deparhnent 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 establishxnent must have at least one Person In Charge (PIC) on site during hours of operation.
1. 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 file at your establishment.
L 2.
HEIMLICH CERTIFICATIONS:
All food service establishxnents 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 file at your place of business.
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 $55
_INN $55 CAMP $55 SWIMMINGPOOL $80ea.
_LODGE $55 =7RAILERPARK $105 WHIRLPOOL $SOea.
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�! LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTTNENTAL $35 NON-PROFIT $30
>100 SEATS $160 � � _COMMON VIC. $60 WHOLESALE $80 �
. � � - —RESID.K[TCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#�
<50 sq.ft. $50 >25,000 sq.ft. $225 1 VENDING-FOOD $25 � � ��! '-C" ,'
=<25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 25 .00
•*••*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 e
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �/
Town of Yannouth taxes and liens must be pai�rior 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 sha11 be
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 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 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 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 srt 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 outdoar 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 Departrnent 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 Yazmouth must nofify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours priar to the catered event. These forms can be obtained at the
Health Department, or from the Town's website at www.yarmouth.ma.us under Health Depar[ment, Downloadable
Forms.
FROZEN DES5ERTS:
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 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 13, 2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), IvtUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: 11 �(8� �3 SIGNATURE: Qj��
�—
PRIN'I'NAME&TITLE:�_Sol<�( /� • (��'L� � P�tri d�ti`t
Rev. 10/08/13
_ ,
. � The Commonwealth ojMassachusetts
Department oflndustrialAccidents
Office of Investigalions
' I Congress Street, Suite I00
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apulicant Information Please Print Leeiblv
Business/Organization Name: �✓G "� -��+t. � ��}" P�c�c�- �i��y u�
Address:� �v4g Qsi-� �r,`�
' City/State/Zip: .�- �S�M✓�'l /�/d- o�f6�- Phone#: �°8— �6� — 2�D°
Ar,�e °u an employer? Check the appropriate boa: Business Type(required):
1.LJ I am a employer with � d employees (full and/ 5. ❑ Retail
oi pa*t-titne).° 6. ❑ ResraursntBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl. real estate,auto,etc.)
employees working foc 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, §1(4), and we have �0.� Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ 9Je aze a non-profit organization, staffed by volunteers, L
with no employees. [No workers' comp. inswance req.) 12•�Other_ �i"i�'1!IJ (:LS �'C/`
•Any app6can[tLat checks box#I must also fill out the section below showing their workers'compensation policy infortnation.
'"If the corporete officers have exempted themselves,but the cotporafion has other employees,a workers'compensation policy is required and such an
organiution should c6eck box#1. � � . � � �
I am an employer that is providing workers'compensation insurance jor my employees. Be[ow is the policy informatian.
Insurance Company Name: �C c�q J�d �� �,s�/�S�« �a .
Insurer's Address: P � ��X �� 3 3 a
City/State/Zip: l� ✓'C 4�� � � 3 �
Policy#or Self-ins.Lic. # �(-' �C 3 31.s'�SS� Expiration Date: � a'
Attach a copy of t6e workers' compensaHon policy declaration page(showing the policy number and espiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fuie up to$1;500:00 andlor"one-year imprisonment,as well as c[iii penalties 'tn thz fotm of a STOP WORK ORDER and`2 fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investigations of the DIA for insurance coverage verificarion.
I do hereby certify, under the pains andpenalties ojperjury that the infornration provided above is true and coned.
Signature: �,�\ ��1�,6� Date• � �� � �J ��
�.�
Phone#: �1 g` y'��— C� �1 83
Official use only. Do not write in this area,to be comp[eted by city or town officiaL
City or To _��-/LPrtu Utld Permit/License#
Issu (circle one):
Board of Heal 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Ot
Contact Person: Phone#: �'-,p$—3't8—�331 x/2�{/
w�+n�maas.onv/Aia -
- ,�, ' ���-o� r
-� � °` `� TOWN OF YARMOUTH Bo�dof
.���
= 1146 ROUTE 28, SOUTH YARMOUTH,MASSACHiJSETTS 026 -2� �� J���'
�� Telephone(508)398-2231, ext. 1241 . Heakh
Fvc(508)760 3472 � ��y � ` '��
f �y��(.�,g��� T, r�s+�au��:
SUN TANIVING ESTABLISHMENTS �`_? -.
APPLICATION FOR LICENSE/PERMIT -2014
Name of Establishment• �(qn��' ��'hels Ta�c ID (FEIN or SSN): �
Address: �1 LoN� Pdnd (�ftv�C.-
Telephone No.: S�g""760 —}3o a E-mail;.� ��' Z24 �@CvMCsf�. nc�- —
Mailing Address (If different from above)• 36S Qo5�'ovl P°J� Rf� S�'� 3 84- S vd��/y /�l/�' ���Z6
Owner/Corporation Name: LI/� � � ��C. • Telephone No.:
Owner/Corporation Address:
Manager's Name: �- �� '�� M d n r L Telephone No.:
Manager's Address:
Under Chapter 152, Sec.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.
Town of Yarxxtouth taxes and lie�s must be paid prior to renewal or issuance of your permits. Please check
appropriately if paid: yes o/ no
LICENSE/PERMIT REOUIRED:
Fee: $55.00 per device
#OF TANNING BEDS: � #OF OTHER TANNING DEVICES� TOTAL �
TANNING DEVICE INFORMATION:
Mannfacturer Model Number Serial Number Tvae of Bulb
�} etir� ��+nd T�ia�;aq f�ndqZzl-cr SD06o��a�' V( ✓
�'C�/`� �5� �K:� �✓hdSZt�[r •S'�d���?s6 �} ✓
Notice:
PERIvIITS RLJN ANNUALLY from January 1 to December 31. It is your responsibiGty to return the
completed application(s) and required fee(s) by December 31. Failure to do so will result in closure of your
establishment until the required application(s)and fee(s)are received. A hearing before the Boazd of Health may
be required prior to reopening.
DATE: �0✓ SIGNATURE:�o��'J�� P�tS I
10/08/13
� � ' � The Commonwealth of Massachusetts
r f � � DepartmentoflndustrialAccddents
Office of Investigalions
� 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aaalicant Information Please Print Legiblv
Business/OrganizationName: �✓G �hC. D Q� P���� � �i�f�
Address: �'� �v�� Qai� Or��C-
City/State/Zip: �- �����'� /�/d' aYf6�' Phone #: �°$' �6� — 2'3°°
Ar,�e °u an employer? Check the appropriate box: Business Type(required):
I.L1 I am a employer with � d employees(full and/ 5. ❑ Retail '
or part-time).* 6. ❑ RestaurantBaz/Eating Establishment '
2.❑ I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl. teal estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. inswance 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 Caze
4.❑ We aze a non-proFit organization, staffed by volunteers, L
with no employees. [No workers' comp. insurance req.] 12_�Other f%t''f h!!J f�5 �r
*Any applicant that checks box#1 must also fill out the section below showing the'v workers'compeasation policy information.
*"If the colporate officeis have exempted themselves,but Ihe cocporation has other employees,a workers'compensation policy is Iequired and such an
organi�afion should check box#1. ��
I am an employer that is providing workers'compensarion insurance jo�my emp[oyees. Below is the policy information.
Insurance Company Name: �C��4��d 1�., �, c v/Ss« r )
Insurer's Address: � � '!��X �� 3 3 a
City/State/Zip: � ✓�e q�� � ` 3 l
Policy#or Self-ins.Lic. # � �r 3 3 Z s'�SS Expiration Date: _I �
Attac6 a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
Failure to secwe coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a
fine up to $1,�0:00 and/or one-yeaz imprisonment, as weli as civil penalties in the form of a STOP WORK ORBEA and a fine
of up to$250.00 a day agai�st 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 certify,under thepains andpena[ties ofperjury that the information provided above is true and correct.
�ienature �� Date• � � � � ��
Phone# �1g _ 4"y3- � `I�B�
Official use only. Do not write in this area,to be completed by city or town oJficraL
City or Town: y��T� Permit/License#
Iss '�gAa+t��eU"� le one):
Board of Health uilding Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office
i 6.Other
' ContactPerson: Phone#: �+R-'�QA-���1 k 12`{�
. www.mass.gov/dia