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HomeMy WebLinkAboutApplications and WC , � ' '� � TOWN OF YARMOUTH BOARD OF H LTH � �P� E� R�rntESS ` ��� APPLICATION FOR LICENSE/PERMI -20�C O.T 2012 '., �� ,;, , * Please complete form and attach all necessary docum ntsl�+;�tkf�@�15 Failure to do so will result in the return of your pac e . ESTABLISHMENT NAME:� 4n �- F; �f J f TAX ID: �� LOCATIONADDRESS:�1 Loha Dahd �rrv� TEL.#: Sog- 760- �3oa MAILING ADDRESS: �—�� OWNER NAME: CORPORATION NAME (IF APPLICABLE): `,✓G `'I �'S C • ' MANAGER'SNAME: C��F M�„ � Z �� TEL.#: SdB-7lU-27�� ' MAILING ADDRESS: I 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. � _. _ _ _�_ ! Pool operatars 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 file at your place of business. 1. Z• 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 file at your establishmenk 1. 2• I PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. , L _ 2.__ _ _— - 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. T6e 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 LODGINC: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# g&B $55 _CABIN $55 _MOTEL $55 INN $55 _CAMP $55 _SWIMMING POOL $SOea [,ODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. - . __FOODSERVICE:— __-__�—_..---- ---. . . . . _- - --- - -------...- - - - - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k � 0-100SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.R. $50 >25,000 sq.ft. $225 �VEND[NG-FOOD $25 �13�75 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 2`�✓' •�o "****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** . r � , �t 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 taaces 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 limited to the temporary and short term occupancy,ordinarily and customazily 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 sha11 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 De�artment to schedule the inspection three(3)days prior to opening. PLEASE NOTE:People are NOT allowed to sit m 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 SEASONAL FOOD SERVICE OPEPIING: 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.yarmouth.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 teims 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,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 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 REQUIRE A SITE PLAN. DATE: 7 f 1- SIGNATURE: � ,� , . PRINT NAME & TITLE: ��S e P� /� • I l,L 2� P r�s���f � Rev. 10/09/12 � :f . . � The Commonwealth of Massachusetts Department of Industrial Accidents Offzce oflnvestigations 1 Congress Slreet, Suite 100 Boston,MA 02114-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auplicant Information Please Print LeEiblv Business/OrganizationName: �/l� n`'� �hL � t� ��Chc �' ��1'h<JJ �S/y1od�� Address I� �InS QJno� nfiV� T City/State/Zip: S- �q�+'\o�}l, h�- Phone#: SJ$ — ?6� — 2�o d Are you an employer?Check the appropriate box: Business Type(required): 1.� 1 am a employer with employees(full and/ 5. ❑Retail -- - - �--- - - - - - -- -------- - or part-tun8}: b. RestauranvBarlEanng�sta 1i`s7�ment 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 warkers' 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 Caze 4.❑ We are a non-profit orgaztization,staffed by volunteers, with no employees. [No workers' comp. inswance req.] 12.�Other F•'.�/��fI ���'r �/� 'My applicant that checks box#1 must also filI ou[the section below showing their workers'compensa[ion policy infortna[ioa . "If the coryomte officers have exempted themselves,but the corporetion has other employees,a workers'compensation policy is required and such an � organization should check box N L � I am an emplayer that is providing workers'compensation insurance for my employees. Be%w is the po[icy injormation. Insurance Company Name: TC G� �d o��1 .,1-h,t��ph l c �v• �� Insurer's Address: � T f���+( I Q`_ q�s�6,�ic . f�� � �-SR c�riis�c�z�p: N�;s�, ✓� F A/ F� v 306 3 Policy#or Self-ins.Lic.# T W�- 3 3� S� �,� Expiration Date: � �- o���.3 Attac6 a copy of the workers' compensation policy declaration page(showing the policy uumber aud expiration date). Failure to secwe coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . . . r�^eer-:e�?,3�&9�a��eae-}r��'.i���eanaear;as-wPll� '-�.�-�m� � �_�*:�ua�thefe*�e�-aS��P-�NNbIAK�ADFA.andafine 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 verification. I da hereby certify,under thepains andpenalties ofperjury that the information provided above is true and conect. Sienatur�T'1A�1T_� � Date: l �- �� B � o� Phone#: � `t i8— 443 — 8 � g 3 Official use only. Do not write in this area,to be completed by city or town o�cia[ City or Town:y�h?_lYI(XI771� Permit/License# u circle one): .Board of Heali . Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's O�ce 6. e ' ContactPerson: Phone#: $DR—.39R-aa3f klLy� www.mass.gov/dia , ��, � /3 -003 �. °� `� TO WN OF YARMOUTH Boardof ��_ °: �r�� ealth " = 1146 ROUTE 28, SOUTH YARMOUTH, MASSACHL7SET S 03C5�=���r' - �o alth Telephone(508)398-2231, ext. 1241 CE� O , 20t2 n ���nn Fas(508) 760-3472 � L D�? , n SUN TANNING ESTABLISHMENTS ' " ��� APPLICATION FOR LICENSE/PERMIT -2013, Name of Establishment: T �5 hc�- �i�bGJJ Telephone No.: �8'7�� —o�� Tax ID (FEIN or SSN): _� � Address:_ I �] �hq PUhd 1��i V L' � Mailing Address (If different from above): Owner;Corporation Name: �G' � i � h L• Telephone No.: Owner/Corporation Address: Manager's Name: C.�i¢ /�'1�ti t'� Telephone No.: Manager's Address: Under Chapter 152,Sea 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. Town of Yarmouth taaces and liens mus be paid prior to renewal or issuance of your permits. Please check appropriately if paid: yes no LICENSE/PERMIT REOUIRED: Fee: $55.00 per device x a = �I(O.O� #OF TANNING BEDS:_� #OF OTHER TANNING DEVICES TOTAL oZ TANNING DEVICE INFORMATION: Manufacturer Model Number Serial Number Tvue of Bulb �CA��IGhtI T�hh��,� Svnc( y22�rr SD (� 7?3�S � [Kq^'FItiMd T5hni5f J�ht{SZL�r!' •SD � 7�6 �_ Notice: PERMITS RiJN ANNiJALLY from Januazy 1 to December 31. It is your responsibility to return the completed application(s) and required fee(s) by December 31. Failure to do so wi�l result in ciosure of your establishxnent unfil the required application(s) and fee(s) aze received. A hearing before the Board of Health may be required prior to reopening. DATE: Q eC, 3 '�( � SIGNATURE: �tr �on�nz � � The Commonwea[th ofMassachusetts Deparlment of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�nlicant Information Please Print Le�iblv Business/Organization Name: �/i� s� �h L `��� ���h c � ���'H<�J �S/Yl od�� Address:�l � c�l.�� �Jn�� n(i V� City/State/Zip: S- ����o��'� f1/�' Phone #: S�g - 76 0 - 230 0 Are yoa an employer?C6eck the appropriate box: Business Type(required): 1.� I am a employer with�employees(full and/ 5. ❑ Retail or pazo-s�e):' . [i: Q RestauranF/Bar�tmg Esta6lishment 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 capaciry. [No workers' comp.insurance required] 8� ❑Non-profit 3.❑ We aze a corporarion 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, �/ with no employees. [No workers' comp. insurance req.] 12•OCJ �her F�� n�fl ��n �r' *Any applicant that checks box#1 must also fill out the secfion below showing their workers'compensation policy infortnation. •�If the corpofate officers 6ave exempted themselves,but the coiporation has other employees,a workers'compensation policy is required and such an organi�tlon should check box N I. I am an employer that is providing workers'compensation insurance jor my employees. Below is the policy information. Insurance Company Name: T<<� •L��M �h J��H h Cc r c� Inswer's Address: a'� T f'el t-�A f S �f f�� � �`rR city/state/zip: �/Ti U 06 Policy#or Self-ins. Lic.# T W�- 3 3 2 S 7 ,�.5 Expiration Date: � �- a��3 Attach a copy of the workers' compensatioa policy declaration page(showing t6e poticy number and eapiration date). FaIlure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a � � fuie�up to�I,SOO.OP andior��ae-yeaz�.isipriwraaer.t,zs�:.�!s civel pP.naltes.in the form of a STOP WORK OADER.�nd 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 Investigations of the DIA for insurance coverage verification. I do hereby certify,unde�the pains and penalties ojperjury that the injormauon provided above is true and correct Sienature� �^ Date• ( a � Phone� `� �8— �43 — 8 4 8 3 Offrcia/use only. Do not w�ite in this area, to be completed by ciry or tawn officiaL City or Town: �A-Q/1'�AL�# Permit/License# u ' cle one): 1: Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Baard 5.Selectmen's Office ContactPerson: Phone#:�8-39f'f3—�3a3/ YIZ�/I www.mass.6ov/dia