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Home My WebLink AboutApplications and WC S . �, a I�2„s,s�`�'�(�r' =' - PR� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERM - , r` ��r•�t �. ^� `' � * Please complete form and attach all � , c nis b,�'De m T „ ,,. Failure to do so will result in th �' tu p��o �i�"ation . ESTABLISHMENT NAM : ( X ID:`' LOCATION ADDRESS: EL.#: - CPO� (� MAILING ADDRESS: I - OWNER NAME: CORPORATION NA APPLIC BLE): MANAGER'S NAM . U TEL.#: "I MAILING ADDRESS r 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 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 �le at your establishment. � �' 1.�� 1�� 2. �� '� 1/ 1� PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. �Qi I �� l_,��c _ 2. 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. 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 _TNN $55 CAMP $55 _SWIMMING POOL $80ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $85 �f 3-03,*� _CONTINENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PEFtMIT# LICENSE REQUiRED FEE PERMIT# _<SOsq.ft. $50 >25,OOOsq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 rrnME crr.aNCE: $ts AMOUNT DUE _ $ 8S�a 0 **"**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 prio 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 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 Heaith Department prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening. PLEASE NOTE: People aze NOT aliowed 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 opeuing. 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 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 Pernut 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,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 RESPONSIBILIT'1'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: O 1 � SIGNATU PRINT NAME & TITLE: I Rev. 10/09/l2 � � The Commonwea[th of Massachusetts Department of Industrial Accidents - Office of Investigations - l Congress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaalicant Information Please Print Leaiblv Business/Organization Name: I Address: I� -� I.LJr 1 � � City/State/Zip � ��r Y 1 � 1 6� Phone#:��- �� - �Ic�_J Are ou an employer?Check the appropriate bax: Business Type(required): 1� I am a employer with�,�Z employees(full and/ 5. ❑ Retail or part-time).• 6. � RestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or parh�ership and have no �_ � 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 a 152, §1(4),and we have 10.� Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.� Other •My applicant that checks boz#1 must also fill out the section below showing their workers'compensation policy infortnation. *•If the colpolate officers have ezempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organizatiou should check box#1. I am an emp[oyer that is pr,o�vi�din w,�or^kers'compensation insur�a,npc�e fo'/r�m employ�ee�s. (B�elnw'isIt,h�e p,orli�c,y injormation. Insurance Company Name:�--{� x �� `��1 tC�� "1„t�"�, �`IN`I�Y.C�� {�-(� Insurer'sAddress:i�`-� ��(� �Y ��..(� City/State/Zip:�ur 1� �1.,� TL,1 \ � �� , ` v� l�(J•;, Policy#or Self-ins.Lic.#��.(,��-I J�I�O I O� Expiration Date: � U Attach a copy of the workers' compensation policy declaration page(showing the policy numbe and e piration date). Failure to secure coverage as requued 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 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 hereb cerhJ,y,under the pains and penalties of perjury that the informarion provided above is true and correct. Si atur Date: ` ` ��G ��J I Phone#: � �l � " 1��-/ �'(\ �X !� Official use only. Do not write in this area,to be completed by ciry or town afficiaC City or Town:�FZi2,�v10�- Permit/License# mg on ' le one): 1.Board of Health 2. uilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office Contact Person: Phone#:�C3-��'/e-r�a31 X 1 Z�( � www.mass.gov/dia � "` , ��;�t � _ _�"L� PR-�S a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PE��y' -�LQ12 � �,�;, , � ,y ,"� ��• �`5' � p �� '�' � � . * Please complete form and attach all necessary doCum�tl Cem r l .�EPT Failure to do so will result in the return ofybur�fplication pac et. ESTABLISHMENT NAME: � TAX ' LOCATIONADDRESS: I7-7L (,11Y11T�J TEL.#: �I�--+�.�-7lo0-3/cd MAILING ADDRESS: OWNER NAME: . �M/� CORPORATION NAME(IF,�'�PLICAB ): MANAGER'SNAME: ►��JD� � TEL.#: �-76U-3 uJ MAII.ING ADDRESS: �„�f- U1V� � 1ZP POOL CERTIFICATIONS: The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool Qnerator(s) and attach a co y of the certification to this_form. i. d� 2. �, Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. T6e 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. 1._- � r-�l?�A" � 2. PERSON IN CI�ARGE: _ _ _ _ _ _ _. Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �( ,✓llA �,��c� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more mus[ have 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 co ies and maintain a file at your place of business. 1. 'VF � 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _llV`J $SS - — . Ca.�3P_. .. . � _.$55- _SWiMMINt'iPOOL $80ea. _LODGE $55 _TRAILERPARK $105 _WHll2LPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-]00SEATS $85 _CONTTNENTAL $35 _NON-PROFTT $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAII.SERVICE: _g�ip I{�� $80 LICENSE REQUIRED FEE PERMTf# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.ft. $50 _>25,WOsq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.fr. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAME CHANGE: $15 AMOLJNT DUE _ $ 85•oo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*+g�* { �� 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 MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED� "'"`�( ��j � '"-""-' OR Gtu� Gu(,�c�{ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ZS�� Town of Yarmouth tases and liens must be paid prior to renewal or issuance of your permits. PI.EASE C�ECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTI�ER LODG�'VG ESTABLiSH1VIMEi+(TS 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 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 tttat is subject to the collection of Room Occupancy Excise, as deFned in M.G.L. c. 64G or 830 CMR 64G> as amended, shall generally be considered Transient. POOLS POOL OPEIVING: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 Department to schedule the inspection three(3)days pnor to opening.PL.EASE 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 Yarmouth Health Department by filing the r�quired 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 Depaztment, 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 wiil result in the suspension or revocation of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: _ - O„tc;de cafe,c(i.e.,ou!do�r seating with waiter/waitress sereice).must have prior approval from the Boazd of Health. OUTDOOR COOKING: 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 THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15> 2011. 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 E A SIT'E PLAN. DATE: �i1��L�SIGNATURE: PRINT NAME 6z TITLE: ��y►-� �� f� Aev.10/25/I l , � �� NOTICE � = NOTICE TO � o TO EMPLOYEES t` EMPLOYEES � , �-• M �• The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street,Boston, l�Iassachusetts 02111 617-727-4900 — http://www.mass.gov/dia As uired by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I�(we) have provided for payment to our injured employees under the above mentioned c6apter by msucing with: TFE TRAVELERS INSURANCE �pMQES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDOLEBORO MA p2344-1450 ADDRESS OF INSURANCE COMPANY (6KU8-4900P56-2-11 ) 12-05-it TO 12-06-12 POLICY NUMBER EFFECI'IVE DATFS � MARSHALL K LOVELETTE INS 396 ROUTE 28 '� WEST YARMOUTFI MA 02673 . ��` NAME OF INSURANCE AGENT qDDRESS PHONE# � CARVALFIO, JASDN DBA 12-2 WHITES PATH � BAGELS & BEVODp � SOUTH YARMDUTH � MA 02664 � EMPLOYER ADDRESS � � EMPLOYER'S WORKERS COMPF�TSATION OFFICER(IF ANy) DATE � MEDICAL TREATMENT . � The above namod ins�u'er is �e;qwred 'm cases of personal injuries a[ising out of and ip the course of � �P�aYment to furniah adequate and reasonable 6ospital and medical services in accordance with the � provisions of the Workers' Compeffiat� Act. A copy of the First Report of Injury must be giv�en ro the � injured empbyee. The employee may select his or her own physiciaa 1be reasonable cost of the services provided by t6e treating physician wilt be paid by the insurer, if the treatment is necessary and reasonably _ connected to the w�ork related injury. In cases reqairing hosprta� attention, employee.c are hereby noti6ed t6at the inaurer has arranged for such attention at the NAME OF HOSPITAL ,ADDRESS _.___.___ TO BE POSTED BY EMPLOYER