HomeMy WebLinkAboutApplication and WC � � d � TOWN OF YARMOUTH BOARD OF HEALTH � � T���.PAR.IL
�, APPLICATION FOR LICENSE/PERMIT, 0 O�� { (�,'�s 11 M(y;�� ��,
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�� * Please complete form and attach a11 necessary� y De mber IS 20 2;'�
Failure to do so will result in the return�o pplicatron acket.
HEi�LTH i�ENi .
ESTABLISHMENT NAME: ' e r � � �e � L� � TAX ID: �
LOCATION ADDRESS:��7 !-✓�//�s, � .�� ,�O��lr 1t� � /�/� TEL.#:.5-C�.�'- ���7U/ /
MAILING ADDRESS:
OWNER NAME: ` o//�
CORPORATION NAME (IF APPLICABLE): `
MANAGER'S NAME: TEL.#: D - -O 0
MAILING ADDRESS:
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. /1//� 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below an3 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.
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 certifica6on to this application. The Health Deparhnent will not use past years'records.
You must provide new copies and maintain a £ile at your establishment.
1. / Y /y 2.
PFRS�J:`�I�T CHn g6E: _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. __�-�l� 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 a11 times. Please list your employees trained in anti-chokuig procedures below and
attach copies of employee certificaUons to this form: The Health Department will not use past years' records.
Yo:► rnust provide new copies and maintain a file at your place of business.
1. Z•
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# [.ICENSE REQUIRED FEE PERMIT#
B&B $55 _CABIN $55 _MOTEL $55
INN $55 _CAMP $55 _SWIMMINGPOOL $SOea. �
LODGE $55 1TRAILERPARK $105 –OO� _WHIRLPOOL $SOea
FOOD SERVICE:
LICENSE REQUIRED FEE PERIviIT# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 —CONTINENTAL $35 _NON-PROFIT $30
� >l00 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 �.
RETAIL SERVICE: . —RESID.KITCHEN $80
I, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T k WCENSE REQUIRED FEE PERMIT ii
� _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25
� <25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95
� NAME CHANGE: $15 � AMOUNT DUE _ $ IO S.60
� •****PLEASE TURN OVER AND COMPLETE OTHER S[DE OF FORM*'*`*
ADMINISTRATION r �I
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �i�
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's II
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ,
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR 'i
CERT. OF INSURANCE ATTACHED I
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth 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 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 principal place of residence j
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 or 830 CMR 64G, as amended, shall generally be considered Transient. ';
POOLS i
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 Deparhnent to schedule the inspection three(3)days
pnor to opening.PLEASE NOTE: People are NOT allowed to sit m 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.
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 Deparhnent,
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 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: '
Qutside ac_fPs(i__P_,nntrinnrseating with waiterL�vaitressservice),m„�r havP prinrap�aval_frnm the Boacd nfIiealth.
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 15, 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 RE UIRE A SITE PLAN.
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DATE: Q /� SIGNATURE: � � � :��� �� ,,� ;aq�
PRINT NAME & TITLE: =�{�l��FL,� ����-�g�+ ���� �
Aev. 10/09/12 �
: ,
� The Commonwealth ofMassachusetis
Department oflndustrialAccidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A licant Information Please Print Le 'bl
Business/Organization Name: ����S `f� r i 1 �✓` / �"Q ��E i" A✓� �1�-
Address: ��QB ����� ���
oa� � q �
City/State/Zip: . � ' F'4'� � Phone #: ,����— 3 !�'���� /
Are you an employer?Check tLe appropri�Ye box: _ _. 8usiness Type(required):
I.❑ I am a employer with employees(full and/ 5. ❑ Retail
�r part-time).* 6. ❑Restaurant/Baz/Eating Establishment
2. I am a sole proprietor or partriership 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.❑ We aze a corponrion 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]*
11.❑ Health Caze
4.❑ We are a non-profit organizarion,staffed by volunteers, �
wittt no employees. [No workers' comp. insurance req.] 12.�Other / }�'Ui /`�1� [!�V' �
•My applican[that checks box#1 must also fll out the section below showing the'v workers'compensation policy infotmation.
"'If the corporate officers have exemp[ed themselves,but the corporation has other employees,a workers'compensa[ion policy is required and such an
organiza[ion should check box#1.
I am an employer that is providing workers'compensadon insurance jor my employees. Below is the policy injormation.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
-- -Palic��3rSeff-ins.:.iee# —_ _ _ -- - - -�_��,..«�__
Attach a copy of the workers' compensation poticy declaration page(showing the policy number and expiration date).
Failure to secwe coverage as requued under Secrion 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a
fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalries 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
Investigations of the DIA for insurance coverage verification.
I da hereby certify, nder the pains and penalt�es of perjury that the infarmakon provided above is true and conect
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Si a��/��/1�n��[� LL�IC�'l�"rfC� Date• !O�'jl//�
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Phone#• ���.�'�CJ� �
O�cia/use only. Do not write in this area,to be completed by city or town officiaC
City or Town: Permit/License#
Issuing Aut6ority(circle one):
1.Board of Aealth 2. Building Department 3.CitylTown Clerk 4.Licensing Board 5. Selectmen's Oftice
6.Other
Contact Person: Phone#:
. . . . ... w,vw.rtwss.gov;dia _. . .