HomeMy WebLinkAboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH C� �� '�/� °j
, ��� APPLICATION FOR LICENSE/PERMIT - 013 , J, � -"�
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' * Please complete form and attach a11 necessarykAocum nts by De mber 1 S 20I2.
Failure to do so will result in the retum o�your ap�lic��o"' T•
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ESTABLISHMENTNAME: QASS R�vG2 .uo7t�G J7J�F3 Z1-c TAXID• �
LOCATIONADDRESS: StG'/ R-7 2Sl SoU71� �r��/�¢.rJ ,�t�d TEL.#:.5�(f-3I���/�
MAILING ADDRESS: t` L aZ d 64
OWNERNAME: /GB ����1 .R� M A-bl �N�R-A� R- !3 f�7"7'
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME�,u q-��a�� 1(�.,A�-1 TEL #• � �'j - � Y°q
MAILINGADDRESS: �,,..� S��— ���/77
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool dperator(s) and attach a copy of the certification to this fomi.
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Pool operators must list a minimuxn 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.
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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.
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Each food establishment must have at least one Person In Charge (PIC) on site d�xring hours of operation.
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HEiMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must haue 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' records.
You must provide new copies and maintain a file at your place of business.
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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 ��7���
— . .. ___. _._ _ . .
. ._ ._- -'__._.. ..--.. .- - --. _.. _--- - - --- _
INN $55 � CAMP S55 _SWIMMING POOL $80ea. /vbf 0(i�1�! �
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 $30
>I00 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
[,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25
_s25,000 sq.ft. $80 —FROZEN DESSEAT $40 _TOBACCO $95
NAMECHANGE: $15 AMOUNTDUE _ $ 55. 00
*****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 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:
YES � NO
MOTELS AND OTHER LODGING ESTABLISI�M�ENTS-• ' '� '
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ordinazily 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 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 sha11 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 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
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 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.varmouth.ma.us under Health Deparkment,
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:
_ Outsicie cafes(i.e.,outdQ�r seating with waiter/_waiYre�ssersricel;m�ist havapriar appraual-f�m Yhe i3uarrl�'He.�ltl��- -
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 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 REQUIRE A SITE PLAN.
DATE: �/� �� -�!Z SIGNATURE: TM�Y�✓Y�✓�1.G` � . ��/
PRiNT NAME & TITLE: �f� }�l „j�,�{t �Z_ _F$/-h���T
Rev. 10/09/12
, � � The Commonwealth ofMassachusetts
Department oflndustria[Accidents
Office oflnvestigations
1 Congress Street,Suite 100
' Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance A�davit: General Businesses
Annlicant Information I�IR l��N"� �} � .l3 Et/a-7T Please Print Leablv
Business/Organization Name:�A-T S �I�tT� Mo 7/--� ���N��
Address:�► Q,r( � �.
City/State/Zip:�' I� ' Phone#: � �.S�l ��1 � �
4re yoa an empbyer?Ghecictk�app¢o rat ox:, _ _,_ Busiqess T�pe(require$?:_ ,
1.❑ I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* S'LLj�— G—Aqp(.0�� 6. ❑RestaurantBar/EatingEstablishment
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. inswance required] 8� ❑Non-profit
3.❑ We aze a corporation 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 workers' comp.insurance required]*
4.❑ We are a non-profit organizarion,staf£ed by volunteers, 11.�Health Caze
with no employees. [No workers' comp.insurance req.] 12.�Other /�'l� 7�L
•My applicant that checks boz#1 must also fill out the section below showing the'v workers'wmpensation policy infortnation.
"*If the corpora[e officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organiTation should check box N l.
I am an employer that is providing workers'compensation insurance for my emp[oyees. Below is the policy injormation.
Insurance Company Name:�/ /.1
Insurer's Address:
City/State/Zip:
_ __�u7icy�oY�eif-'u�1s.LiG.#�- — -- -- -- —-- £a.piratisn.�te:— —-- -- —
Attach a copy of the workers' compensation policy declaration page(showing the policy number aud expirallon date).
Failure to secure coverage as required under Section 25A of MGL 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 agaiast the violator. Be advised that a copy of this statement may be forwazded to the Office of
Invesrigations of the DIA for insurance coverage verification.
I do hereby certify,under the pains and penalties of perju that the injarmation provided above is true and conect.
Si@nature: 9y1 Y„/(�vUl� 1Q--a�-.�✓�Y�` Date: ��— .L� —�'�.
Phone#: l � � ' 6 �'1�p �
Ojficial use only. Do not write in this area,to be completed by city or town officiaL
City or Town: y�Q�tb(JT}} Permit/License#
Is Nte 'rcle one):
Board of Health 2 Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
ContactPersoo: Phone#: �8-3�1c4—aa3� X �2�1�
.. . . . , . _. ___ ._ .. _ . - -www.mass�govidia ., . . __. __ . ___ _,. . . ._ .. _ _ . ...