HomeMy WebLinkAboutApplication and WC � • .. �..� __ v�.'J
� � TOWN OF YARMOUTH BOARD OF HEALTH I
�� APPLICATION FOR LICENSE/PE T- 0 �'"'� " ; L'U i;
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* Please complete form and attach all nec�� mb
Failure to do so will result in the r�tu�'o �p` li��tt , Y PT
e:,., �. .-
ESTABLISHMENT NAME: ' T
LOCATION ADDRESS: .�a�_ Ba�,�iS.C.a.��J .P17 �.u�y.a.e TEL.#: _�'a,p �9.� 7_ yy�i
MAILINGADDRESS: /6- w.9.cTi/ft�'/ �i.c� c=tE u�E'si�/st,r�ineu%/�� �»r9 t��?673
E-MAIL ADDRESS:
OWNERNAME: fILFFrri s<r�.v.c�.gin
CORPORATION NAME (IF APPLICABLE): �q/�i�'/�! /d,L,r' ,
MANAGER'SNAME: �}L�Ei'Y/ Jltf-ti�P�QA-/!� � TEL.#: _��-3cSo�23�
MAILING ADDRESS: /�_ c.��.c i,NArrI ��iP�LE �v yi�Pmn��� rY/f3 a a�73
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 ployees currently certified in basic water ety, standazd First Aid and
Community Cardiopulmonary Resusci 'on(CPR),having one certified employee o remises at all times. Please list
the employees below and attach co ' of their certifications to this form. The th Department will not use past
years' records. You must pro ' e new copies and maintain a file at yo lace of business.
1. 2.
3. 4 '
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-6 employee who is certified as a Food Protection
Manager, as defined in the State Sanitary Code for Food Service tablishments, 105 CMR 590.000. Please attach
copies of certification to this application. The Health Dep ent will not use past years' records. You must
provide new copies and maintain a file at your establi ent.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at st one Person In i,harge (PIC)on site during hours of operadon.
1. � 2.
ALLERGEN CERTIFICATTONS:
All food service establisliments are required to have at least fixll-time employee who has Allergen certification,as
defined in the State 'tary Code for Food Service Estab ' ents, 105 CMR 590.009(G)(3)(a). Please attach copies of
certification to ' application. The Health Depa ent will not use past years' records. You must provide new
copies and m ' tain a file at your establishme .
1. 2.
HEIMLICH CERTIFICATIONS: �
All food service establishments �Gvith 25 seats or more must have at least on employee trained in the Heimlich
Maneuver on the premises at adT times. Please list your employees trained in -choking procedures below and attach
copies of employee certifications to this form. The Health Department ' not use past years' records. You must
provide new copies anct inaintain a file at your place of business.
1.
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 SWIMMINGPOOL $SOea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $l60 COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSEq REQUIRED FEE PERMIT# LICENSE REqQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT#
�<25,000 sq.ft. $80 c�—v � �ROZEN DESSERT$$40 1 TOBA CO FOOD $95 �3
NAME CHANGE: $15 AMOUNT DUE _ $ I�S.On
*•**•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 WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE
COMPLETED AND 5IGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yannouth tases 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 sha11 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 sha11 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 Heaith 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 5ERVICE 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.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 Departsnent. 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 Boazd 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 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 AN APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLA�
DATE: ��e,.._ /�y' SIGNATIJRE:
PRINT NAME &TITLE: ,q,�,c,c� y.�j,�Uap,p�}-/y/ �%Q,E �� / )
i
Rev. 10/OS/13
. � The Commonwea[th ofMassachusetts
Department oflndustria[Accidents
� Office oflnvestigations
' 1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance �davit: General Businesses
Annlicant Information Please Print Leeiblv
Business/Organization Name:
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Bus_ ingss Type(required):
1.❑ I am a employer with employees(full and/ 5.���Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
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.insurance required] 8• ❑ Non-profit
3.�'J We aze a corporation and its officers have exercised 9. ❑ Entertainment
� ` their right of exemption per c. 152, §1(4), and we have �0.� Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, I 1.❑ Health Care
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'u workers'compensation policy information.
**If the cotporate officecs have exempted themselves,but the wrporatlon has other employees,a workers'compensafion policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance jor my em . Below is the po[icy info�mation.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
policy#or Self-ins. c. #_ Expiration Date:
Attach a copy of the workers' compensation policy deJc ar< on page(showing the policy number and espiration date).
Failure to secure 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-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 forwarded to the Office of
InvesUgations of the DIA for insurance coverage verification.
I do hereby certi er the paiqs and penalties ofperjury that the injormatian provided above is hue and correct.
Si ature: � Date:
Phone#: ��� .- `i�0 - '�i o`� ��
Officia!use only. Do not write in this area,to be completed by city or town offuiaL
CityorTown: yqQ�p�� Permit/License#
circle one):
1.Board of Healt 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmeds Office
r
12y I
Contact Person: Phone#: b`��3- Yg-y 23 1 X�
www.mass.gov/dia
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H�ALii-? C�PT.
0�'p'Mf�� 2012 - 2014 �
Massachusetts Department of Revenue
� = Cigarette and Tobacco Excise Unit
:'" Retailer of Cigarettes, Cigars and Smoking Tobacco
6
D00.
This Temporary Voucher must be posted and visible at all times. Sales to persons under 1 B years of age are prohibited by aw.
i
Application Number. A��OZ �
� Fedarai Identification or Social Security Number
� -- —
_ _.___ ----.–_.._.. .__.__..__— .
"-- � �� - -� Salelocation �'
Mailing address tor ticense: ', BUCKY'S '�.
AKMU ING 52g gUCKISLAND RD ,
528 BUCKIS�AND RD YARMOUTH, MA 02673
WESTYARMOUTH, MA02673 __ __ ___________ ___--''
--__ __ _ —
_ _ --_.
---- ,.
This document signities that the business location listed above has requested a Ocense to sell tobacco products. This confirmation voucher s a
onry be used untll ihe receipt of the permanent license,at which pant this document is null and voi0.
� Massachusetts �
Department of Revenue
PO 8ox 7004 �
Boslan,MA 02204-7004
� AKMU INC. _
528 BUCKISLAND RD �
WEST YARMOUTH, MA 02673 .
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