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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALT,H ��`'�� E"`��' _ � APPLICATION FOR L ^' �R1�IIT-20 4 ^_ Q 2 (U i 3 * Please complete form and attach a1�n �uments y D , i Ol3 � Failure to do so will result`iK thesreturn of your appli ESTABLISHMENT NAME. AX " � LOCATION ADDRESS:O� TEL.#. — — (� MAILING ADDRESS: E-MAII,ADDRESS: OWNER NAME: CORPORATION NAME �IF APPLI BLE): MANAGER'S NAMET 1 EL.#. MAILING ADDRESS. . 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),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: 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 Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. �.�Sl� (12-�C�(�fl ll a. V i � � i�P� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. �1 '�1 L�a�1� --- 2. ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who has Allergen certificarion, 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.�1� � � �� _� 2. HEIMLICH 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 all times. Please list your employees trained in anti-chokuig 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 REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMINGPOOL $80ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL � $80ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-100 SEATS $85 �� _CONTINENTAL $35 NON-PROFIT $30 >I00 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. $SO _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOLTNT DUE _ $ �j. GG *'**•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 INSiJRANCE 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 of Motel or Hotel use, Transient occupancy shall be limited to the temparary 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 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 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 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. 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 Yannouth 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 obtairied 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 ar 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 ar food service establishxnent 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.), MiJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE PLAN. DATE• � SIGNATU PRINT NAME& TITLE: 1 � � Rev. (0/08/13 • , � The Commonwealth of Massachusetts . Department oflndustrial Accidents Offzce oflnvestigations ' l Congress Street, Suite I00 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: Address�a —a (,t��l�C�'� 1.�� . (� City/State/Zip� . hone #:�(��S '�� Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with�_employees (full and/ 5. ❑ Retail or part-tin;e).* 6. RestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, Office and/or Sales(incl. real estate, auto, etc.) employees working far me in any capacity. [No workers' comp.insurance required] 8• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We aze a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#I must also fill out[he section below showing their workers'compensation policy informatioa . **If the corporate officers have exempted themselves,but the cotpora6on has other employees,a workers'compensation policy is required and such an organization should check box#1. � � I am an employer that is providing wo{rkye�rs'compe'n's�Lat�ion insurance for my employees. Belo�w d�s t�he p�olicy information. Insurance Company Name:� 'C . 1 y � . �VCT(l�'��.��1� � � Y )1 1 II� �� •� . ��>>G �C�� ,�.� Insurer's Addres . City/State/Zip: �� I � l� ��(�� — L J'-'1 1�� Policy#or Self-ins.Lic. #��IJL.` �a��P��'rJ��S—r-�'71�Expiration Date: �'JD Oti/�"1 Attach a copy oFt6e workers' compensation policy declaraHon page(showing the policy number and eapiraHon date). Failure to secure coverage ac required under Secfion 25A of MGL c. i 52 can lead to tne 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 Invesrigations of the DIA for insurance coverage verification. I do hereb rti under the ains and penalties ofperjury that the injormation provided above is true and correct. Si atur � ) Date: ( Phone#• � � - l��"'�� Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(cirde one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's O�ce 6.Other Contact Person: Phone#: www.mass.gov/dia