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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH T�E PRroc.qk.� � ,� � � � � t � ,� APPLICATION FOR LICENSE/PERMI -�033��==� � ' � ��% �'� � � * Please complete form and attach all necessai�t.d�c � s� � ec mbeli�t'L��3 � Failure to do so will result in the returci�f y application ac et. �ct�i_ ,� ,�;_'Nl . ESTABLISHMENT NAME:I! � I�a r�C 1 � ID: LOCA'I'ION ADDRESS: � � TEL.#S'o ' 8-9y3Z MAILING ADDRESS: �� 5v��^ � OWNER NAME: CORPORATION NAME(IF APPLICABLE): e p KS N C.�.5� MANAGER'S NAME: V�P�as t� �� P. �� ` �L.#: s��- e - �s y MAILING ADDRESS: � Z Pep ��r= 2� ou i�r �t42�n aaA ili U� d ZL��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. �: _ __. _ - _---- - —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 file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishxnents aze required to have at least one fixll-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 certificadon 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. U1�YOCCEA �l'taPW b4 2. ��S � ��l'Pu/ /'YLC�it`e-S PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. - 1._�2b Qcc63 �j r� 2. _ IIEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the�Ieimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifica6ons to this form. The Health Department will not use past years' records. You must provide new copies af'd maintain a file at your place of business. 1. G hh ahd Z e� f'Yla-��' ��.Qf 3. � G!�/9?C[/� � �C 4. �a �s-t�4 . J �sKs RESTAURANT SEATING: TOTAL# I�� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55� CAB[N $55 _MOTEL $55 _INN $SS _CAMP $55 _SWIMMING POOL S80ea. LODGE $55 TRAILERPARK $105 _WHIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT t! LICENSE REQUINED FEE YERMIT# L1CbNSE c rn -- 0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 �>I00 SEATS $160 �� I COMMON V[C. $60 �t/3-o44� _WHOLESALE $80 � RETAIL SERVICE: —RESID.KITCHEN $80 j � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD S25 _Q5,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $l5 AMOUNT DUE _ $ 2-�.O.OC) �.. ***"*PLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM"•*`! � ADMINISTRATION � Under Chapter 152,Section 25C, Subsection 6,the Town of Yazmouth is now reqwred 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 taxes 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 limita6ons 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 thiriy(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 OPErIING: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 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. . _ FOOD SERVICE SEASOI�TAL 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 Yazmouth Health Departsnent by filing the required Temporary Food Service Applicadon form 72 hours prior to the catered event. These forms can be obtainedat the Health Depaztment,or from the Town's website at www.yarmouth.ma.us under Health Deparhnent, 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 Pernut 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 COOKING: 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 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO 2,PPROVED BY THE BOARD OF HEALTH PRIOR TO COMM CEMENT. RENOVATIONS M Y UIRE A SITE PLAN. DATE: � ` 'I.� 1 � SIGNATURE• PRINT NAME & TITLE: X "��L� (� Rev. 10/09/12 � � � The Commonwealth of Massachusetts Department oflndustrialAccidents Office oflnvestigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A licant Information Please Print Le 'bl Business/Organization Name:` � ��VJC..�l�-� I � IV N L 1 � Address: S �--� City/State/Zip: � � fth DU b��hone#: 5 �� —3 �I$ � �.S� Are you an employer?Check the appropriate box: Business Type(required): l.❑ I am a employer with employees(full and/ 5• �Rfxail _ _ - -- - _, orpart-tSme).� - --- - -- - -b:" Res�uranLBar/�atingEstaBiishme�it --- -- _ 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.rea(estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] $� ❑Non-profit 3.❑ We aze a corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4),and we have 10.❑Manufactnring no employees. [No workers' comp. inswance required]* 4.❑ We aze a non-profit organizarion,staffed by volunteers, 11.❑ Health Caze with no employees. [No workers'comp.insurance req.] 12.❑ O[her *Any applicant that checks box#1 must also fill out the secfion below showing the'u workers'compensation policy infmmation. *•If[he coryorate officers have exempted themselves,but the wrpora[ion has ather emplayees,a workers'compensation policy is required and such an organization should check box#L . I am an empinyer that is providing workers'eompensation insurance for my employees. Below is the policy informadon. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 uD f0$1 SOU.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Sne _ _� .-- -- -- ---- -- of up to$250.00 a day against the violator. Be advised that a copy of this sfatement may be forwazded to the O�f Investigations of the DIA for insurance covenge verification. I do kereby certify,under the pains and penalties of perjury that the injormation provided above is due and correct ' Si�ature: Date• Phone#: O,�Scial use only. Do not write in this area,to be completed by city or town officiaL City or Town: 'yF}�10(T(� Permit/License# Is ' ' 'rcle one): Board of Healt .'Bui�ding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.O er Contact Person: Phone#: S�8—39F3-3a 31 X 12�(( www.mass.gov/dia �O,Rd° PANCIM1 OP ID:MF "�.-�-� CERTIFlCATE pF LlABlL1TY tNSURANCE °"'��'�°°'"ri' 7HI3 CERi1FlCAlE IS�SUED AS A MA7iER�IMFQRNR71q!ONlY MW Q77291t3 CERTIFICA7E OGES NOT nFF�eW1T1VELY OR kEGI171VltY ApOENo, �S MG FEIDNTS UPON'�F�t�7tT1FICATE NOtnER iH� ' �LAW. TN0.i CEft17F7CATE OF INSl7RANCE �!S N07 CON6ifT1lfE�� O� � TF18 70E.ICIEB R�PREBENTATIV!OH PAOp�ICEq,AND THE CFJlTMIGATE FWLOER. �� T� I�UNKi ��g� Al1lFlatl�0 INPORYAIIT: �tla a hIXd�r b an ACo1Tl0�, p1SURFA, PadICYW�)�t be ondawd. ff en.arma and eondltiw�s p�uis p�cy��n poAelp muy rea�e an anawsertwnt. A�t�w�on tlda��rigt�ila m q� aaruflwmr holdor of eueh H�e �Ca�Cadlrrurriea ?�:'�-7Ti lAartl�F �� FaF�8-7T5-9821 508-7T133�0 . 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