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Home My WebLink AboutApplication and WC • T�++� PaNca�MaN`�' ` � TOWN OF YARMOUTH B APPLICATION FOR LICE� � � `-+� 14 . JAN 3 � ZO14 * Please complete form and attach a11 nec� s ec ber 13 2013. Failwe to do so will result in the return of your applica . ESTABLISHMENT NAME: ., Q � U —o • LOCATION ADDRESS: 1 S�- 'R �s 2 8 -.r',..�(q,�mr,�rai TEL.#: ti J�'-��jSr-�I�'3 L MAILING ADDRESS: P. � , C3 .i_��l B t-1.� nn�s �o � Mn �z�y"� E-MAIL ADDRESS: Cs n.-�c A k G • o M OWNERNAME: C nac.At�� p.� � �,-(J CORPORATION NAME�IF• APPLICABLE): MANAGER'S NAME: Ih A�Q51 �L � p tI c� y'� yTEL.#: S'ag-7�F 6L 2 Z� MAILING ADDRESS: � P,� �c S"� � ��G A+1 1 � Y`�cY �k Q t..6�� POOL CERTIFICATIONS: The pool supervisor must be certi£ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttus form. :�'� 1. 2. Pool operators must list a minimum of two employees currenfly certified in basic water safety, staudard First Aid and Community Cazdiopulmonary 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 of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establislunents are required to have at least one fixll-time employee who is certified as a Food Protecrion 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 uae past years' records. You must provide new copies and maintain a file at your establishment. 1. ��3�ccA S-rooc�-s �oi.�,c.O 2. � 1'{ ti�G�l PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 4-Ca.T3CGG A .7��ILJ �/JLt.f�) Z. 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. 1.ae�.��'3 h 2. � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich Maneuver on the premises at a11 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. �Q�.� 2. 3. 4. RESTAURAN'I' SEATING: TOTAL# � �D � OFFICE USE ONLY LODGING: L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 �NN $55 CAMP $55 SWIMMINGPOOL $80ea _LODGE $55 _TRAILERPARK $105 �� _WHIRLPOOL $80ea FOOD SERVICE: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# .0-100 SEATS $85 CONTINENTAL $35 NON-PROFIT S30 �>100 SEATS $160 � l COMMON VIC. $60 ��(o �UHOLESALE S80 � � — � —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'1'# <50 sq.ft $50 >25,000 sq.ft. 5225 VENDING-FOOD S25 =<25,000 sq.ft. $80 -FROZEN DESSERT $40 _TOBACCO S95 NAME CHANGE: $15 , AMOUNT DUE _ $ ZZO a�O "•""*�LEASE TETRN 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: j 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, ardinarily 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 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 aznended, 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 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 standazd 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 SEItV��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 Yarmouth must notify the Yannouth 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, pr from the Town's website at www.vazmouth.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: Outdoor cooking,prepararion, 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 ESTABLISHME T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND PP OVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ I �PLAN. pATE: l- Z t- I�� SIGNA'TURE: PRINT NAIvIE&TITLE: �(/�A&S lkl�(;� � . �r I e� � � ra.�_ a�. iorosns � � The Commonwealth ofMassachusetts Department of Industrial Accidents Offace ofinvestigations � I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anulicant Information Please Print Leeiblv Business/OrganizationName: ��1e C Al.�� r �u �'`�'' Address: � ��' �'C� 2 � City/State/Zip: � �G�.rh o�K� �� Phone#: 5�°5 - 3�'(Y — �J �j`L- Are u an employer? Check the appropriate box: Business Type(required): i.�I am a employer with.�employees(full and/ 5. ❑ Retail orpart-t'r.ne).* 6. [�AesfaurantBartEatingEstabIishment , 2.❑ I am a sole proprietor or parluership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑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]* 11.0 Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other 'My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informffiion. •*If the coipoiate officers have exempted themselves,but the corporetion 6as other employees,a workers'compeasadon policy is required and such an organization should check box#L � � � � I am an employer that is pro iding workers'compensati�on, insurance for my employees. Below is the policy injormation. Insurance Company Name: sb�-� a T P� � n u�T�.J�c s e� � 5� �u.�A�- �V 'i �� Insurer's Address:5�' 1 l��C.�O �j� �� ri,s��,Z�p: a ��I ,� �, -I� M h� o� � �3 Policy#or Self-ins.Lic. # �� L �00 I �D � j (� �"LU I � Expiration Date: � '�'- �`! Attach a copy of the workers' compensation poGcy declaration page(showing the policy number and eapiration date). Failure to secure coverage as required under Secnon 25tT of IvIGL c: i 52 can lead to ifie imposition of criminal'¢enaifie�of 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 fonvazded to the Office of Invesrigations of th IA for insurance coverage verificarion. I do hereby ce , er e pains and penalties ofperjury that the injormation provided above u true and correc4. Si ature: Date: �-�\� r Phone#• S°b `�� J qS � Officia[use only. Do not write in this area,to be completed by city or town officiaL City or Town: �/4RAt4ttTN Permit/License# Iss ' ut o ircie one): 1. ard of Healt . Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's O�ce 6. Other ContactPerson: Phone#: 5a8-3F��31 X ��`�� www.mass.gov/dia f