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HomeMy WebLinkAboutApplication and WC�— - � -, n 2�v�$Eac.H '�' �� TOWN OF YARMOUTH BOARD OF HEALTH �� "- Co(ilc SIoN j APPLICAITON FOR LICENSE/PERMTI'-20ll pp ti Q�f1 � � k * Please complete form and attach all necessary documents by Dec mber IS'�� ` � � �w ' Failwe to do so will result in the retum of your application ac �,;,�. �,�-� � L y � ESTABLISHMENT NAME: HYA�✓�/�S /� ��19/�^ TAX ID: LOCATIONADDRESS:B9SS R1vF2 R�.9GN TEL.#: MAILING ADDRESS: V �y/S �R 6 OWNERNAME: leciAr� ' �+i[N CORPORATION NAME (IF APPLICABLE): /�YANN/S /Cf �Rf.9M ('OR ' MANAGER'S NAME: /,jl C C ,EPjk.2^� TEL.#:7J�/-y�� G,iI MAILING ADDRESS:�°O �b,X SS—/ S. �i�.t//S �H A cl,�2 /_ G 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 minimuxn of two employees cunently certified in basic water safety,standazd First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee cenifications 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-tune employee who is certified as a Food Protection Manaeer, as defined in the State Sanitaiy Code for Food Service Establistunents, 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. l.t✓�LU�.rr �.g(,.�2n� z. L��✓J9 6�3��i✓ PERSON IN CHARGE: - - _.__ Each food esiablisiunent must have at least one Pei•son In Charge(PIC) on site duivig hours of operation. 1. CH{2t57/N,t M/ CF/.9NC' 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 tixnes. Please list your employees trained in anti-chokuig 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 Gle at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODG6\G: LICENSE REQUIRED FEE PERMII'� LICENSE REQUIRED FEE PER�fIT� LICENSE REQUIRED FEE PERMIT� B&B S55 CABIN 555 MOTEL S55 � — — I INN S55 CAivf? 555 �S��-LYIlb1i:.`G PCOL SSOe4. LODGE - S55 . IRAII.ERPARK SI05 �'VHIRI.POOL 580ea. FOOD SER�ICE: LICENSE REQUIRED FEE PERMIT= LICENSE REQUIRED FEE PER\9T= LICENSE REQUiRED FEE PERMIT� I 0-100 SEAiS S85 I��? _CONTINENI'AL S35 _NON-PROFI7 S30 >I00 SEATS S160 � COMMON VIC. S60 ��Z-IOLESALE S80 RETt11L SER�'ICE: —RESID.KI'ICHEN 580 iLICENSE REQUIRED FEE PERM[I'# LICENSE REQUIRED FEE PER�IIT* LICENSE REQUIRED FEE PERMIT R _<SOsq.R. S50 _>25,OOOsq.ft. 5235 VENDING-FOOD S25 <25,000 sq.ft. S80 _FROZEN DESSERI' S40 _70BACC0 S55 �a��c�ta.�cE: s�s AMOUNTDUE _ $ SS.00 I '""""pLEASE TIIRS 04'ER A\D CO�IPLE'IE OTHER S[DE OF FOR�1*•""* � } � 4 � ADIIIINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or peimit 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 prior to renewal or issuance of your pernvts. PLEASE CHECK j APPROPRIATELY IF PAID: YES NO � 1l�IOTF.LS AND QT'HEB LODGIN�ESTABLISHMEAITS TRANSIENT OCCUPANCY: For purposes ofthe 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 principa(place ofresidence elsewhere. Transierrt 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 Health Depamnent prior to opening. Contact the Health Department to schedule the inspection tluee(3)days pnor to opening. PLEASE NOTE: People are NOT ailowed to sit m the pool azea unril the pool has been inspected ; and opened. POOL WAT'ER TESTING: The water must be tested for pseudomonas,totai 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. PUUL CL05ING: 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 inspecrion three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must norify the Yarmouth Health Depaztment 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 I Forms. f � 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 suspens�on or revocation of your Frozen ' Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/wait;ess service),must have prior approvalfromihe Boazd ofHealth_ _ � OUTDOOR COOHING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishmetrt is prohibited. � f � NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTTY TO RETCTRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVE BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ IR E PLAN. DATE:�/.�- �l SIGNATURE: � — PRINT NAME&TITLE:Ivy L L /9.�^ ,�,BU.¢�/ �o j�.F✓c'� 10/06'10 � ,._. } ' . � The Commoawealth of Massachusetts P�''"t F°"n Departmext of Industrial Accidents Ojj'ice of Investigatio»s 600 R'ashington Street Boston,MA 02I11 www mass.gov/dia Workers' CompensaHon Insurance Affidavit: General Basinesses Aoalicant Information - Please Print I.eeibiv Business/Organizafion Name: Hyannis Ice Cream Corporation Address:Po eox sst City/State/Zip: 5°uth Dennis MA 02660 phone#:5083853788 Aro yoa ae employer?C6eck tLe appropriate boz: Business Type(regnired): 1.� I am a employer with �Z employees(fiill a�d/ 5. ❑Retail or part-time).* 6. ❑ReslsuranUBar/Eatmg F�stablishment 2.❑ I am a sole proprietor or pazmership and have no 7. ❑Office and/or Sales(i�l.real estate,auto,etc.) employees working for me in azry capaci[y. [No workers'comp.insurance required) 8. ❑Non-profit 3.❑ We are a corporation and its officers have eacercised 9. ❑Entertainment the'v right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance requ'vedJ' 4.❑ We are a non-profit organizetion,s[affed by volunteeas, �I.�Health Care with no employees. [No worlcers'comp.msurance req.] 12.�Other �ile vending 'Aoy epplicant that c�cks box#I�st also fill out tlie section below showing ticeir workecs'compeosetion policy iofocrostion. srlf the corporaze ofiicers have exempted themsedves,but the corponHon has mlu,v wployees,a walcers'com�wnsstion policy is reyuirat apd surAan_ . . .._.. . . .orrgan�tion sfiouldcheckbox#t. - ._ _... _ ___ _. _.. _ .._. . . .. - . _. I am a»emp/oyer that is provi�dng workers'compensation insuroncejor my employees. Below is the palicy injo��wtion. Inswance Company Name:Anaiated Employers Insurence Company Insurer's Address: P•O.Box 4070 City/State/Zip: Burlington,MA 01803-0970 �.o i/ Policy#or Self-ins.Lic.#5002883012070 E����:6R7IiPi6 Attach a copy of the workers'compensition policy deelarataa page(s6owiog t6e policy num6er and ezpintioo dste} Failure to secure coverage as requircA under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fine up to$1,500.00 and/or one-year unpriso�ent,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�is statement may be fonvazded to the Office of Investigations of the DIA for' tttance cov e verification. I do hereby c , paias ond penaBies ofpery'ary tk�u tke iry'o��tion provided above ic due and comert Si : � ' Date: %�- �� Phone#: 50&77Cr2000 O,,(j'icia/use only. Do not write in tkis areq to be comp(etad by city or town oj,)''uiaL City or Town: PermiULicense# Issaing Authority(circk one): 1.Board of Heak� 2.Baildiog Department 3.CitylPown Ckrk 4.Licensiog Board 5.Selectmen's Office 6.Other Contact Person� Phone#: � www.mass.gov/a;a �