The URL can be used to link to this page

Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALT �r��J�� 4p�-� • � � APPLICATION FOR LICENSE/PE I 1 � '�'� � NOV 15 �013 * Please complete form and attach all neces� , , c eh b 'December 13. 2013. Failure to do so will result in theAefu�,of�our;appli� rio�p�k�.DEPT. ESTABLISHMENT NAME: T �- LOCATION ADDRESS: TEL.#: MAILING ADDRESS: Sa4l� E-MAII,ADDRESS: �(Qrt/��o��'��t f�N�� OWNER NAME: CORPORATION NAME (IF APPLICABLE): � � C. MANAGER'S NAME: �f�p�1�L ,rJc�i�C� TEL.#: _S/�S'—��J'�"-OS�/� MAILING ADDRESS: �'iaas/� 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. L�j� 2. �t//✓ Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 forxn. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ,t�Y�l�i 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �F/!4 2. PERSON IN CHARGE: Each food establishxnent must have at least one Person In Chazge (PIC) on site during hours of operation. 1. /��{� 2. ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one fixll-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. /1��l4 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-cholang 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. N/,4 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY [.ODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 —INN $55 CAMP $55 SWIMMINGPOOL $SOea 1 LODGE $55 -�-Co4 _TRAILERPAItK $]OS _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR$D FEE PERMIT# WCENSE 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 �PERMIT# �LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# <50 sq.R. S50 >25,000sq ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: S15 AMOUNT DUE _ $ 5 5 +O O ****•PLEASE TURN OVER ANIICOMPLETE OTHER SIDE OF FORM***`• L . I 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 MUST BE ' COMPLETED AND SIGNED, OR ii CERT. OF INSURANCE ATTACHED-- j OR i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � ; Town of Yarmouth taa�es 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 i _ _ _ _—_------ ---- � --- - --- — -- • - __ _ —— _ _ ----- � 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. 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 sha11 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 j 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 aze NOT allowed to srt 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 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 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 Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter, with sample results i submitted to the Health Department. Failure to do so wiil result in the suspension or revocation of your Frozen Dessert Permit until the above terms haue been met. OUTSIDE CAFES: i Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishxnent 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 REQUI E PL DATE: �-/��/3 SIGNAT'CJRE: PR1NT NAME&TITLE: � J Rev. 10/08/13 � ,. � , � The Commonwealth ofMassachusetts • Department oflndustrialAccidents Office of Investigalions � 1 Congress Street, Suite 100 Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Leeiblv Business/Organization Name:��S �v EQ ��(v 4 - Address: ��/rr/4C',,4�T S%� City/State/Zip: � ' Phone#: 5p�-3�=�t�0 Are you an employer? C eck the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail _pf pazt-timej.* 6. ❑ RestauranUBar%Eating Establishment 2.�" I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate, auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We aze a corporation and iu 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.❑ Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 must aLso Sll out[he section below showu�g their workers'compensation policy inforniatioa. *'If the wxpora[e officers have exempted themselves,but the corporation has other employees,a workers'compeasation policy is required and such an otganization should check box#1. � � I am an employer that isproviding workers'compensation insurance for my emp[nyees. Be[ow is thepolicy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compensafion policy declaration page(showing the policy number and expirarion date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penaities of a fine up to$1,500.00 and/or 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 this statement may be forwazded to the Office of Inves6gations of the DIA for insurance coverage verification. I do hereby certi , r the pai and pe alties of perjury that the information provided a6ove is hue and correcx i Si ature: Date: — — Phone#: 4�'= Official use on[y. Do not write in this area,to be comp[eted by city or town official City or Town: YA,OM�,n} Permit/License# Is u o 'rcle one): .Board of Health 2. uildiug Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office Contact Person: Phone#: SD8 —3 4 8-2231 x �LY� www.mass.gov/dia