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Home My WebLink AboutApplication and WC :. TOWN OF YARMOUTH BOARD OF HEALT �khS��.�ty✓�)B �� APPLICATION FOR LICE�I.S�/EE I �20� CoNt�S N kPR 2 9 �1i * Please complete form and attach a11 xi'ecess�ry ��s b December 1�. 2�13. Failure to do so will result in t�i5 ret�t�.�yp�}r ' tior��ky�t�.�r�T ESTABLISHMENT NAME: ' LOCATION ADDRESS:��/�.vnrFn (30.�.�,2 T'EL.#:_SdR •77��a00 b MAILINGADDRESS: PO !',mc Scl C. fZo.,�,,,.k� m r9 �)ab60 E-MAILADDRESS: vRn�Nrslre crPww��a w�l . Cor�-, OWNERNAME:��I;An-. �' J ��IaW� c° RUIQhJ CORPORATION NAME (IF'APPLICABLE):�/n.,,.vu�o . �rQ C�h v�„�.. MANAGER'SNAME: J.iNDA c�'ClUI�YJ TEL.#: Sd1f''�76� ao0d MAILING ADDRESS: S`q m e 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 operatars must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR),hauing one certified employee on premises at a11 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. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to haue 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. �.L��0�•ns.,, �� 2. ..r�.a ��/ .n.� � tn-- PERSON IN CHARGE: Each food establishxnent must have at least one Person In Charge (PIC) on site during hours of operation. �. t,U..�D,,,,y,.. �'�,,,,� 2. ALLERGEN CERTIFICATIONS: All food service establishments aze 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 tlus application. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your establishment. 1. �.� ��pt�Lrr� C 9X�[U!n> 2. �n> � 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-choking procedures below and attach copies of employee certifications to this form. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a file at your place of business. l. W.�try�,. �yi.itn�.� 2. LG.Hsl/e� ��iun�- 3. 4. RESTAURANT SEATING: TOTAL# _ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 MOTE[, $55 �NN $55 CAMP �$55 SWIMM[NGPOOL $80ea —I.ODGE $55 'I'RAILERPARK $105 _WHIRLPOOL �80ea FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�i L0.I00 SEATS $85 �� _CONTINENTAL $35 NON-PROFIT $30 >100 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 sy.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD S25 _<25,000 sq.ft. $SO -FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ �'S:CO � *•**•PLEASE TORN 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 MiJST BE COMPLETED ANDSIGNED,OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces 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 temporary 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. i Transient occupancy shall generally refer to continuous occupancy of not more than tliirty(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 i 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 OPErTING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department priar to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People aze 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. 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. I CATERING POLICY: Anyone who caters within the Town of Yazmouth must no6fy the Yarmouth Health Department by filing the required Temparary Food Service Application form 72 hours priar to the catered event. These forms can be obtained at the Health Department, or from the Town's website at www.yannouth.ma.us under Health Department, Downloadable Forms. I FROZEN DESSERTS: I 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 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 COOKING: 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.), MiJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �-lb-1� siGNa�rUxxE:l�,.�j �C�',p�-n,,.. PRINT NAME&TI'TLE: i�n}��'(�IJ�nJ - p wwe r Rcv. 10/08/13 � ' The Commonwealth of Massachuseus , Deparhntnt of Indushial Accidents O,fJ`iee oflnvestigations 1 Congress Sireet,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insnrance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organizadon Name��bs��_��o ( v - Address: N�-J L�� (�p PC� Q� sc� , J City/State/Zip: �. D,P.r,nw� M 1� Phone#:� dC R'• '7`]�_�I2�7� Are ou an employer?Check U►e appropriate box: Bus��ss'1�'Pe�re4nlred): 1� I am a employer with��employees(full and/ 5. ❑Retail or part-time)." 6. ❑ RestaurantlBaz/Eating EstabGshment 2.❑ I am a sole proprietor or partnership and have no 7, � Office and/or Sales(incl.real estate,suto,etc J employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and iis officers t�ave exercised 9. ❑Entertainment their ri t of e�te fion r c. 152, §1(4),and we have anufactmin g1� mP Pe 10.0 M g . insurance re uired s no em lo ees. [No workers' comp q ] P y i l.� Heakh Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employee.s. [No workers' comp. insurance req.] 12.�Other 'Any applic�t that.chedcs box#t must also fitl out the section below showing their workers'compensatioa policy infotmati�. "'If the cotporate officeis have exempted themselves,but the corporation has other employees,a workeis'compeosation poliry is required and such� �. organi�tion should check box#1. � . . I am an employer that is prov�iding workers'compensandon insurance for my employees. Below is the policy informatioa Insurance Company Name:�/�l�M'�n� !' -.��.�t ��Q��n,r�.+.c v Insurer's Address: City/State/Zip: �•,n�. �rr �} Policy#or Self-ins.Lic.# �.t� C C �(')n a k'�.? ]',J 1� F.�cpiration Date: �'�� Attach a copy of the workers' compensation poticy declaration page(showing the policy nnmber and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andlor 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 tlris statement may be forwarded to the Office of Inves6gations of the DIA for insurance coverage verification. ' I do hereby certify,under the pains and nalties ofperjury that the information proutded a6ove is true and wrrect Signnature�L w� ��(.se:� Date• �'�� Phone#• �d�'77�' �n00 O,(ficial use on1y. Do not write in this area,to be complefed by city or town offictaL City or Town: yttP-MOJ-t�,1 Permii/License# Iss ' c�rcle one): Board of Hea 2.Bnilding Department 3. City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other ContactPerson: Phone#: 5�3��R-3a3� .C�Zy� www.ma4s.gov/dia