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Home My WebLink AboutApplications and WC �i9 �Bc-�cor�� ` �� TOWN OF YARMOUTH BOARD OF HEALTH� � r z�� J �I�J , APPLICATION FOR LICENSE/P� ]�T �8i�3 j �. , °" fE� ,' ,`� � ' ? ,°ax , * Please complete form and attach all ne�l1ss r� oet.i��t�it�`by''� cember IS 2012. ,�,. Failure to do so will result in the return of your applicatio a TH DEPT. ESTABLISHMENT NAME. TA ID• LOCATION ADDRESS: TEL. —~( � MAILING ADDRESS: OWNER NAME. CORPORATION NAME (IF APPLI ABLE): MANAGER'S NAM � , _ �L.#� — �XD —I I MAILING ADDRESSi i� Qr�l rI 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. 1. 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 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 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. /�� SS �. �U�� mc,c�-� 2. �`:�^91►2 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �.�.Tu I c� r'Y1r�c�..� 2. �t�� l v�2 g H�IMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at ali 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. 2. 3. 4. 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 _INN $55 _CAMP $55 _SWIMMING POOL $80ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FCE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 I3'�37 _CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $60 I.7�� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _<SOsq.R. $50 >25,OOOsq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: $15 AMOLTNT DUE _ $ IyS.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 ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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 eisewhere.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 ar 830 CMR 64G, as amended, shali generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far 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 aze NOT allowed to srt 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 thereafrer. 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 Yarmouth 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,or from the Town's website at www.varmouth.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 Deparhnent. 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 Board 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 RESPONSIBILTTY 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 M REQUIRE A SITE PLAN. DATE:� v{ �d �� SIGNATURE: PRINT NAME & TITLE. �� r Rev.10/09/12 � The Commonwealth ofMassachusetts Department of Industrial Accidents ' Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name. Address: City/State/Zip: 1 �U Phone#:��— �q�� `��'jU(� Are you an employer?Check the appropriate box: Business Type(required): 1� I am a employer with�_employees(full and/ 5. ❑Retail or part-time).* 6. Q]RestaurantBaz/Eating Establishmern 2.❑ I am a sole proprietor or pazmership and have no 7. � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance requued] g� ❑Non-profit 3.❑ We aze a corporation 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.❑Health Caze 4.❑ We aze a non-profit orgazuzation,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other *My applicant that checks box#1 must also fill out[he section below showing the'v workers'compensation policy information. "If[he coryorate officers have exempted themselves,but[he co=poration has other employees,a workers'compensa[ion policy is required and such an organization should check box#1. I am an emplayer that is providing�w/o�rkers'co ensatian insurance for my�e,m(�nlo�ees. Below is the po[icy info on. Insurance Company Name�� 1 %I ��1�1�� l71'I"lQ�� ,��aQ` �s----.` ' `�� ,�,1 �� Insurer's Address:��' , r ,�` �—�(.p�� v� City/State/Zip: r 1� V� Policy#or Self-ins.Lic.#� �� Expiration Date:� � Attach a copy of the workers' compensation policy declaration page(showing the policy numbeS•and e piration date). Failure to secwe coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains andpenalties ofperjury that the information pravid d above is true and correct Si atur � ( Date: ,� � �� Phone#: Official use only. Do nat write in this area,to be completed by city or town officiaL � City or Town: A-�Ld7J`�1� Permit/License# Iss ' le one): .Board f Health 2. uilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office . r Contact Person: Phone#: 6"D�-3 `�R—aa.�l x'lZ�/L www.mass.gov/dia a TOWN OF YARMOUTH BOARD OF HEALTH ' ''- �� APPLICATION FOR LICENSE/PERMIT -201 � �, � A� � . : 8 � * Please complete form and attach all necessary docqments y:l� de� �EPT. Failure to do so will result in the return of your application pa ' ` ESTABLISF3MENT NAME: � ' LOCATION ADDRESS: �( W`� f'V�i� TEL.#: S�dF:7�U-�S� MAII.ING ADDRESS: OWNER NAME: , � 1-� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: -'I$d� MAILING ADDRESS: �� (V1J'Ci 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 forni. 1. � Pool operators must list a minimum oF two employe curre y c rt' e ' ba ' water safety, standard First Aid and Community Cazdiopulmonary Resuscitation ( ). P ase i th ployees below and attach copies of employee certifications to this form. The Healt ment ill n use past years' records. You must provide new copies and maintain a file at your lace of business. I. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFTCATIONSi All food service establishments aze 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 Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years'records. You must provide ew copies and maintain a�le at your establishment. 1. c�6� �� 2. _ PERSQN IN CHARG��---__._ _- - -- - Each food es biishment must have at least one Person In Charge(PIC)on site during hcurs of operation. 1. �� L�51u�t�K� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee uained 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 copi and maintain a file at your place of business. 1. �� 2. 3. 4. RESTAURANT SEATING: TOTAL# �oncnvc: OFFICE USE ONLY LICENSE REQUQtED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _1NN $55 _CAMP � $55 �SWIMMfNGPpBL y�0ea - _LODGE $55 _1RAILERPARK $105 _ _WHIRLPOOL $80ea. __ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTT N LICENSE REQUIRED FEE PERMIT# I 0-100SEATS $85 I '(�� _CONTINENTAL $35 _NON-PROFIT $30 _>]00 SEATS $160 LCOMMON VIC. $60 �l a-a7I _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTC# _<SOsq.fr. $50 _>25,OOOsq.fr. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOiJNT DLTE _ $ /�{S• OO •*'"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth 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 A1V'D SiGNED, OR CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta.ees and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES� NO _ Ni07'EL3 EIIVS3 CTiI"�R i.�I'i�ft'+i�E�Tt'�SLF�'ri0'S'i;ATg'S 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 demonsuate 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 Deparunent prior to opening. Contact the Health De�artment to schedule the inspection duee(3)days prior to opening.PL,EASE NOTE:People aze 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 standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. 1'OOL CLOSING: Ever�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 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,or from the Town's website at www.yazmouth.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 Pernut until the above terms have been met. OiTl'SIDE CAFES: n„«,�_��sa�s t;.e.;�L-�=s�»--=__^�,*,iT�t=.�aiterl••,,aisess servi�A?>m:�si?�zve�rior ag�rovsl fre.^.:�he�oar3o£?��. OUTDOOR CQOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts 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, 2011. Ai.i. RENOVATIONS TO ANY FOOD ESTRBLISHMENT, 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�;�:�� J�E A STI'E PLAN. DATE: �/M�W SIGNATURE: PRINT NAME &TTI'LE: c J�� y �� / Rev.]0/25/11 , • � (� NOTICE � � NOTICE TO " TO � � 0 A EMPLOYEES t� EMPLOYEES .� , � 09M S�e The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, lbtassachusetts 02111 617-72'7-4900 — http://www.mass.gov/dia As required by Massachusetts General Law,C6apter 152,Sections 21,22&3Q this will give you notice that I(we) have provided for payment to our in�ured employees under the above mentioned chapter by uvsuring with: TFE TRAVELERS INSURANCE COIA�ANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDI.EBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (6KU6-4900P56-2-11 ) 12-05-71 TO 12-05-12 POLICY NUMBER EFFECfIVE DATES �� MARSHALL K LOVELETTE INS 396 ROUTE 28 � � '�'"T� WEST YARMDUTH MA 02673 � NAME OF INSURANCE AGENT ADDRESS PHONE# --��- � CARVALHO, JAS�1 DBA 12-2 WFIITES PATH � BAt�LS & BEVOND � SOUTH YARNpUTH �`� MA 02664 EMPLOYER ADDRESS � � � EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE � MEDICAL TREATMENT � The above named insurer is required in cases of personal injuries a[ising out of and in the course of � employment to furuish adequate and reasonable hospital and medical services in accordance with the � provisions of the Worke�' Compensation Act. A copy of the Frst Report of Injury must be given to the � injured employee. The employez may select his or her own physician. The reasonable cost of the services � provided by the treating 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 notified that the insurer has aaanged for such attention at the NAME OF HOSPITAL ADDRESS ___ _._ TO BE POSTED BY EMPLOYER