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Home My WebLink AboutApplication and WC � � � TOWN OF YARMOUTH BOARD OF HEALTH��"" � - � � APPLICATION FOR LICENSE/PERMIT -2014 ��... g� �V� P��d � ��20�;� � * Please complete form and attach a11 necessary documents b ecember 13 2013. Failure to do so will result in the return of your applic ion ESTABLISHMENT NAME: rt ss LOCATION ADDRESS: 6.7 }�ia�r�� 6a.c� TEL.#: MAILING ADDRESS: � f! �Z(o E-MAIL ADDRESS: i� S . JS OWNERNAME: T� o -� CORPORATION NAME (IF APPLI A LE): MANAGER'S NAME: s TEL.#: D�• ' � 9 MAILING ADDRESS: � �f 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 certificati n to this form. 1. 2. Pool operators must list a minimum of o e �ees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resusci on C ,having one certified employee on premises at all times. Please list the employees below and attach copie th ir rtifications to this form. The Health Department will not use past years' records. You must provide e c p�es and mamtain 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 Protecfion 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 cop► s and maintain a file at your establishment. 1. �/}Y� //Ct,[�I/IS 2. �Lui�llyd6� PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �. �4� �/Pw,� 2. P�� ,��- � 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 Sanitazy 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. i. /�on f�e,�� ,i�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-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' rewrds. You must provide new copies and maintain a �le at your place of business. 1. /ri�2 �/1S 2. /"s�li� �iP.a'//'�Dy/ 3. Qor�;S �� 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 1NN $55 —CAMP � $55 SWIMMINGPOOL $SOea. � � _LODGE $55 - _TRAILER PARK $105 _WHIRLPOOL $SOea FOOD SERVICE: � - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 y��4-Oyo CONTINENTAL $35 NON-PROFIT $30 >]00 SEATS $(60 �COMMON VIC. $60 �#'�'Zh: —WHOLESALE $80 � RETAIL SERVICE: � .—RESID.KITCHEN $80 � LICENSE 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 AMOiJNT DUE _ $ �,1p,�v� . � *"**`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 1, 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�' 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 of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temparary 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 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 Departxnent prior to opening. Contact the Health Departrnent 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. ___ —_. _ ___ — — _ F�OIf SEIF�It'E---- - _ __. _ _ - -- - 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 Yannouth must notify the Yarmouth Health Deparhnent 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.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 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: I Outdoor cooking, prepazation, or display of any food product by a retail or food service establishxnent 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., PAIN`I'ING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU��/"'-' E PLAN. DATE: ' /_..3 SIGNAT[JRE: G�i Yl �o�� PRINT NAME &TITLE: �or�A�.r� �ew i�5 O� rov�Cr�+^� Y,�� Rev. 10/08/13 �, � The Commonwealth ofMassachusetts ` Department ofindustrial Accidents Office oflnvestigatdons 1 Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance �davit: General Businesses Analicant Information Please Print Le�iblv Business/Organization Name: �G �r,�� /l�� ,,�.SS /�>dP�/" Address: /o� f//9��/l� �UCcc� —� City/State/Zip: wT�/ O �Phone #: SO�- 77/f-,S�D� Are you an employer? Check the appropriate bos: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail or part-tirnz).* 6. Q RestauranrBaz/Eating Estabiishment 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 aze a wrporation and its officers have exercised 9. ❑ Enter[ainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No worke�s' comp. insurance required]* 11.� Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' wmp. insurance req.] 12.❑ Other 'Any appGcaat that checks box#1 must also fill out the section below showing the'v workers'compensation policy informaflou. '•If the cotporate officers have exempted themselves,but the coiporation has other employees,a workers'compensation policy is required and such an orgariiza[ion should check box#I. � � I am an employer that is providing workers'compensation insurance for my employees. Below ds the policy information. Inswance Company Name: Insurer's Address: City/State/2ip: Policy#or Self-ins.Lic. # Exp'uation Date: Attach a copy of the workers' compensation policy declaraHon page(s6owing the policy number and expiration date). Failure to secure coverage as reqcrired under Section 25A of MGL c. i 52 can lead io the imposition of criminal penaliies oi a fine up to$1,500.00 and/or one-yeaz imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for inswance coverage verifica6on. I do hereby certify,u er th ains a enalKes ofperjury that the injarmatton provided above is true and correcG Si igiature_ ` ��G��SL�C�-c��t-� Date: �/T�/?i � Phone#: � Official use only. Do not write in this area,to be comp[eted by city or town ojficiaL City or Town: ��,�p�77-b. Permit/License# Iss ' circle one): 1 ar of Health . Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: 60B�3 L�$-yZ31 X!L`i I www.mass.gov/dia