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Home My WebLink AboutApplication and WC 4—" a c�� ; _ . , �orl , s :, �, c � � � TOWN OF YARMOUTH BOARD OF HEALTH �, APPLICATIONFORLICENSE/P�;��`"'� C[� � Z ZO�Z '.< '`I * Please complete form and attach a11 necessary a ocuments by➢e� � be EPT. Failure to do so will result in the retui'a7�nf your applicahon p . ESTABLISHMENT NAME:(��_,{��uQr �3Pl�c 1, TAX ID• � .� LOCATION ADDRESS: TEL.#:.$' 8' G MAILING ADDRESS: L3 SS�/ .S. !�P rUro i S �'h t� n�b�� OWNERNAME:�,/ran,,.> f c .fce CrP�r}. CORPORATION NAME (IF APPLICABLE): X1 m�a MANAGER'S NAME: l.t)j )�,`1�1 n-, �t3 U IQ N � TEL.#: y 7 Y- �/�7-/6 3� MAILINGADDRESS: {>O SS /�S Y�Pn,n�ls ml9 Oati(, n 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. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitarion (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. FOtji3 F20 i"��`Pi�N IvI1'�idAf'sET.LS =C�ii3�£fG':�TI3Ids: _ __ _ _ -- . ------ -, - All food service estabiishments 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. �,l Zj � � I q h� [�Y3 U I� Yv 2. NF��,�'(1 iQ h� PERSON IN CHARGE: Each food establishxnent must have at least one Person In Charge (PIC) on site during hours of operation. 1. �.0 i ti� �� w, �t3 U b2 Y� 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-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�le 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 t! ,, _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $80ea. '. LODGE $55 TRAILERPARK $105 WHIRLPOOL $80ea i - -_. _F4ORSFRViCF� � LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $85 ( �O _CONTINENTAL $35 _NON-PROFIT $30 I� h >]00 SEATS $160 _COMMON VIC. $60 WHOLESALE $80 � RETAIL SERVICE: —RESID.KITCHEN $80 I 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. $80 _FROZEN DESSERT $40 _TOBACCO $95 i NAME CHANGE: $15 AMOUNT DUE _ $ 85 .00 **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"*•* ADMINISTRATION , � Under Chapter 152, Secrion 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensafion Insurance. THE ATTACHED STATE WORKER'S COMPEN5ATION 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 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 ar Hotel use,Transient occupancy sha11 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.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 ar 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 opemng. Contact the Health Departrnent to schedule the inspection three(3)days prior to opening.PLEASE NOTE: People are NOT allowed to sit m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 witlun the Town of Yarmouth must notify the Yarxnouth Health Department by filing the 'i required Temparary 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: 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 revocahon of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoar seating with waiter/waitress service),must have prior approval from the Boazd 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 RETLJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER I5, 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: �/b 'i a SIGNATURE: ��, PRINT NAME& TITLE: �.,i,�Y�p. c�{�^ ()y, It� - I� jr� Rev. 10/09/12 .��> . �` � The Commonwealth of Massachusetts Department of Industrial Accidents OfJace of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aoalicant Information Please Print Le¢iblv Business/Organization Name:�V V� N��c' 1 Cfl �Y',a�4 ri„ Address: p� SS� City/State/Zip: S. �P�vrJ 1 S I+1�'1 0��,��OPhone#: S�F�S- 77 6'ad'�� Ar�e an employer?Check the appmpriate box: Business Type(required): l.TJ I am a employer with�(�employees(full and/ 5. ❑Retail or part-time).` 6. estaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or paztnership 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.❑ W e are a corporation and its officers have exercised 9. ❑Enter[ainment the'u right of exemption per c. 152, §I(4),and we have �0.❑Manufacturu�g no employees. [No workers'comp.ins�uance required]* 4.❑ We aze a non-profit organizarion,staft'ed by volunteers, 11.❑Health Caze with no employees. [No workers'comp. insurance req.] 12.❑Other *My applicant ihat checks box#1 must also fill out the section below showing their workers'compensation policy infoimatlon. ••If the corpoxate officers have exempted themselves,but the coryoration has other employees,a workers'compensa[ian policy is required and such an .. .organizationsnouTdckeckbox#1._—._.._. _._ __.—_.____._,.: ____— _. __. .. __—. _ . . . . . . I am an employer that is providing workers'compensation insurance for my empinyees. Be[ow is the poGcy information. Insurance Company Name:Fl S SOC lrr-��,�j __�ir'�L�Y/tt n S� Insurer's Address: 13v2 L r �/C7v --� n.i /1 City/State/Zip: Policy#or Self-ins.Lic.# �✓cc s�a�8'30�a o � 3 Expirarion Date: G Attach a copy of the workers' compensation poticy declarallon page(showing the policy numbe and expiration date). Failure to secure coverage as required under Secrion 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$1,SOU.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Sne 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 certi ,under the pains and penalties ofperjury that the injormation provided above is true and conect Si��1�1� � � ��x�,,,` Date: / 7 ��S 'I� Phone#: Sd� — �7� .�O'(Td Ojficfa!use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: �}(j�d'i�t Permit/Licease# Issui ut o le one): 1. ard of Health 2. uilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. ther Coutact Person: Phoue#: l`Z8—,�1�—c�3 � k��'�� www.mass.gov/dia