The URL can be used to link to this page

Home My WebLink AboutApplication and WC _ � ' � TOWN OF YARMOUTH 3'� r>'��5��ti u' S�D �!'HE,�1� �� APPLICATION FOR LIC�fr e14 � �i; � OZ313 ` * Please complete form and attach a11 n�e�ess " � ntS by ecember 13 2013. Failure to do so will result in the return of your applica on FH DEPT. ESTABLISHMENT NAME: A'� � ��C —� L A-i�. % � � TAX ID: .�� LOCATION ADDRESS: � U I� ' TEL.#: �r �� MAILING ADDRESS: �s+� l�'1 � t�L E-MAIL ADDRESS: OWNERNAME: � 'G'�^ � CORPORATION NAME IF PLIC L .1:_ MANAGER'S NAME: � ��`r TEL.#:C?�� " �% ZZ–'� MAILING ADDRESS: �O U 'v�� - POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State Iaw. Please list the designated Pool Operatar(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 Cle 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-rime 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 Deparhnent 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. Z• ALLERGEN CERTIFICATIONS: All food service establishments are required to have 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• HEIMLICH CERTIFICATIONS: All food service establishxnents with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list yow 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 FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 � —CONTINENTAL $35 NON-PROFIT $30 >]00 SEATS $160 COMMON VIC. $60 WHOLESALE $80 — — . � —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE � P�R4MIT#� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. � $50 I G�� >25,000 sq ft. $225 VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40- _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 3 L.C� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � , , ' : ADMINISTRATION . � 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 WOIiKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE ' COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yannouth taxes and liens must be paid pripr to renewal ar 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 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 thiriy(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 coilection 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 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. . _ —_ _ _ __- . �'OOY3 SEAVICE - 5EASONAL FOOD SERVICE OPE1vING: 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 obtained at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health Departrnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sampie 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: 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 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 RE UIRE A SIT PLAN. DATE: !��3� I3 SIGNATURE: �E PRINT NAME&TITLE: �� '�1��1 Rev. 10/OS/13 ~ � TheCommonwealthofMassachusetts Department oflndustrialAccidents � O�ce of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses ApnGcant Information Please Print Legiblv Business/Organization Name: f�7�LCS" �^��-v /'�ZJe�r�P Address: �- 1�� 0'(�i.zJ� ..1�( �y� � p � City/State/Zip:�. I��s�x�(''�! C�� Phone#: ~C�� 7� �� Are y an employer? Check the appropriate box: Busin s Type(required): 1. I am a employer with�_employees ul and/ 5. Retail o:par:-tisr:z).* 6. ❑ AestauraniBarBaiu.g Estabtisiunent 2.❑ I am a sole proprietor or par[nership 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 c. 152, §1(4),and we have 10.❑ 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.❑ Other *Any applicant that checks box#1 must also fill out the section below showing the'v workers'compensation policy information. *'If the corporate officers have exempted themselves,but the coiporation has otfier emp(oyees,a workers'compe�sation policy is required and such an organization should check box#1. � � � I am an employer that is providing workers' ompensation insurance for my employees Below is the policy information. � � p �— /� Insurance Company Name:_ � �U�-l2U.a'i y �dkrcJ I/Ci,at.e� �—c� Insurer's Address: �� v��1�fv� �45� �� / City/State/Zip: (�/��d � �� r Policy#or Self-ins. Lic. #�� / � 3 2� Expuation Date: � � �� Attach a copy oF the workers' compensallon policy declarallon page(showing the policy number and expiraflon date). Failure to secare coverage as required ur.derSection 25A of MGL c. Y52 can lead to the imposition oi cri�tir,ai penalties oi 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c under the ains nd pe lties ofperjury that the information provided above is true and correct. Si atur • � - Date: 3 Phone#: � '�li�6 l�� 6 Official use only. Do not write in this area,to be completed by city or town ojfictaL City or Town: �$(/.,�'bt0U7t� Permit/License# Is u circle one): Board of Health Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmeds O�ce 6. Ot e Contact Person: Phone#: $b8—�9'f3—Z2.-7i/ ,Y /2-�(� www.mass.gov/dia