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Home My WebLink AboutApplication and WC ;:- : � �� '�J T WN OF YARMOUTH BOARD OF HEALTH Pr$�' '--� � �� 1�14At LICATION FOR LICENSE/P RM�IT,p�-�2�014. ` MF� '��ease com ete form and attach all nece'ssar�ifrierif"s by� ember 13 20134 NEpLTH D�1 to do so will result in the retufii o€yaur�apglieatio pac��tpi Tu, pGpT. ESTABLISHM TNAME: B�p�1I�iL e�dBTfcL TAXID: � LOCATION ADDRESS: TEL.#: � SfSl MAILING ADDRESS: Cn�1 r�____�_��sl„-0.�n�)�� - �,t�- r>2 L L� � E-MAIL ADDRESS: .r--� OWNER NAME: �f�4[�f�-�lL� J2 < � t-l-R`77 CORPORATION NAME (IF APPLICABLE): S',,��,��-1-j�-�1c� LL C MANAGER'SNAME: K�7K�/�1' 2l��t-f � TEL.#: ,52F�� 3�9-�fi�9 MAILINGADDRESS: �TI fL� d-�A4�"1� S"'t' _ rti�U-fl-F '�r��z-sut . ,DZCd�- POOL CERTIFICATIONS: Y � v�L j 5 C LflJ �� N�� QL��L� 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. 1. � 2. � Pool operators must list a minimuxn of two employees currently certified in basic water safety, standazd First Aid and Communiry Cardiopulmonary 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: ,jV �- -� �QL�C��. All food service establishments aze required to have at least one full-fime employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code far 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 establishment. 1. / 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. � 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to haue 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. � 2. y 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 all times. Please list your employees trained in anti-choking procedwes below and attach copies of employee certifications to this form. The Health Deparhnent 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 LODGING: , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT B&.B $55 CABIN $55 �MOTEL $55 �/ –0 7NN $55 CAMP $55 SWIMMINGPOOL $SOea _LODGE $55 =TRAILER PARK $105 WHIRLPOOL $80ea FOOD SERVICE: - � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: � � 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 =�'ROZEN DESSERT $40 —TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ SS, OU **'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** .. -. ADMINISTRATION - Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 MiIST 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: / YES N 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 terxn 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 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 Department priar 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 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. ---_ - _ __ _ - _ ___ - _._ _.— . FU015 SERVI�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 Departrnent, or from the Town's website at www.yarmouth.ma.us under Heakh Deparhnent, Downloadable Forms. FROZEN DESSERTS: �' Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so wiil 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, 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 13, 2013. 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: JJ� "� - �j SIGNATURE: '}✓�I�u c�-`�- V�'- `?✓�" PRINT NAME&TITLE: M�N"�'i�.�� . -� «� Rev. ]0/08/13 . ` . ' � The Commonwealth ofMassachusetts Department of Industria[Accidents Office oflnvestigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Aftidavit: General Businesses A Gcant Information Please Print Le 'bl �55 �--- �-(c1 '�� Business/Organization Name:�CLI� ��) D��,��^�s� �, �,� } � (�' . -� Address: �i' �7 � �-7- .2�►�-(�� S( '' City/State/Zip: Phone#: 3rb�i ��I��"'Z'1 � Are you an employer? Check the appropr�ate ox: Business ype(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-rimej.* 6. ❑ Restnuranf/Bar�'Eating Estabiistunent 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 corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. ]52, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.Q Other n� a ��L *My applicant that checks box#1 must also Sll out the section below showiag the'v workers'compensation policy information. **If the corporate officers have exempted themselves,but the coxporation has other employees,a workeis'compensaflon policy is required and such an organization should check box#L � � � I am an emp[oyer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: CitylState/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensafiou policy declaration page(showing the policy number and eapiration date). Failtse to securc coverge as required under Sec�tiun 25A of NGL c. 152 can lead to the imposition of criminal penalties 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the infarmation provided above is true and correM. Signature: �,_ �3�L.�(i/l Date: ��— �'/ � Phone#: ✓ Official use only. Do not write in this area,to be completed by city or town official City or Town: yA-(U�o V'�j Permit/License# Iss ' ' (circle one): 1 Board of Healt 2.Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Contact Person: Phone#: SOB�f'19-223( X 12`I� www.mass.gov/dia