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Home My WebLink AboutApplication and WC� � . � � � TOWN OF YARMOUTH BOARD OF HEALT$- ' [�[��L� DD ' �� APPLICATION FOR LICENSE/PE . T�013 'i ° NOV 13 2012 �� * Please complete form and attach all necessary c�cum�nta y I3ecem r IS 2012. " Failure to do so will result in the return o ybur application pac1 et. HEALTH DEPT. ESTABLISHMENTNAME: S'��+� ,�fl�i:S TAXID: 04 -�/�/ 3�¢ I�ocaTiorr a��ss: /� o �, ��t � rEL.#: .�e�,��'¢,�.� n�r.rrrG aDD�ss: cr u G � 2 � , � OWNERNAME: fAJL Ol--on2yCo CORPORATION NAME (IF APPLICABLE): ' MANAGER'SNAME: ��h/L CIuL-o�-hao TEL.#: ,� - 77G-�7.�6' MAILINGADDRESS: ZI e A��i� 2,.r� C. .S'na.�w�<<�F/Lli� �� zS-�?7 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pooi Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. — - �• -- -- _ - - - _ _ _- -- -�.--- Pool operators must list a minim of employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary es citation (CPR). Please list these employees below and attach copies of employee certifications to this form. he Health Deparhnent will not use past years' records. You must provide new copies and maintain fi our 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 Protection Manager, as defined in the State Sanitary Code for Food Service Establishxnents, 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 establishment. �.� Nt�3�� z. ��n-h� �U��ti PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. - _ - ----_ __- - - - - -- - `---------�___ _ . HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one empioyee trained in the Heimiich Maneuver on the premises at a11 tunes. 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 fite at your place of business. 1.��'J ,�/IAYd'r� 2. 'f�ry-t�i v1l�o {¢y�o{zG= 3. ANi f��v C' v 2�L4 4. —� RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $SOea. _LODGE $55 _TRAILERPARK $]OS WHIRLPOOL $80ea. FO(1D CFRViCE:_ _ .. .- __ _- _. _ . ._. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI"I# LICENSE REQUIRED FEE � PERMIT# LO-100SEATS $85 .t�13-0'L� _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $160 1COMMON VIC. $60 �I _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 L[CENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _ _VENDING-FOOD $25 � _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $9_` NAME CHANGE: $15 AMOUNT DUE _ $_I't'S.O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , � i ' � 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 Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTEL3 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,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 sha11 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 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 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 priar to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FGt3I3 SERS'ICE 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 Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed 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: 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 I 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 RE UIRE A SITE PLAN. DATE: �l �ia� � � SIGNATURE: PRINT NAME& TITLE: fh/L C�dLoN� �� Rev. 10/09/12 � NOfiICE � NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts Geneml Law, Chapter 152, Sections 21,22 &30,this will give you notice that 1(we)have provided for payment to our injured employees under the above-mentioned chapter by insiuing with: MA Retail M��c�ants WC 6roup Inc. NAME OF INSURANCE COMPANY PO SoX l59222-9222 BralntPe�. NA 012D5 ADDRESS OF INSURANCE COMPANY 014005032775112 � 1/O1/2012 - 1/O1/2013 POLICY NUMBER " EFFECTIVE DATES Rags�s 6 6�ay Insurance Agenty PO Box 1601 434 Route 134 Sout� Dennis, MA 0266� NAME OF INSURANCE AGENT ADDRESS PHONE# Ssafoo0 Sa�'s ]U06 Rts 28 South Var�outh. MA 02664 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COIvI�ENSATION OFFICER(IF ANS� DATE MEDICAL TREATMENT The above named ins�uer is required in cases of personal injuries arising out of and in the coutse of employment to fitrnish adequabe and reasonable hospital and medical services in accordance with the provisions of the Wor&e�s' Compensation Act. A copy of the Fast Report of Injury must be given to the mjured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the heating physician will be paid by the insurer,if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby norified that the rns�uer 6as arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER