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Home My WebLink AboutApplication and WCr � ' '�� a TOWN OF YARMOUTH BOARD OF HEALTH — �� APPLICATION FOR LICENS�lF��N��, / JI IL � i �U15 � * Please complete form and attach all neces�do en 5_ y Dec ber I S 2014. L:'�1_ � nT �' _r' Failure to do so will result in the returtt of your application � ESTABLISHMENT NAME: �' �� P T TAX ID: �� LOCATION ADDRESS: I C�n-I-P r . -e TEL.#: ��-g�� MAILING ADDRESS: � E-MAILADDRESS: . �1 �54� c�nPC(�fI�AP S-�2��-� �� C'� ,�c.� OWNERNAME: '��WQ" S / �. CORPORATION NAME (IF APPLI ABL�I: ti C' �2.e �22 t--�-C MANAGER'S NAME: ✓�'� ��z- Y �� t �, TEL.#: MAILING ADDRESS: � C P r�{-er .4.�C Mo � vr -r'�a? O� G 7 'S� T POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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. I� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid � and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach eopies 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. 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 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. f�'� f�� ' �"q �� 2. I PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. !V i')��c f., 1 / ''J S �L� 7`13f� 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 this application. The Health DepaMment will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. Z• � HEIMLICH CERTIFICATIONS: ; All food service establishments with 25 seats ar more must k�ave at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list yow employees trained in anti-chokmg 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 file at your place of business. l. Z• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$I l0ea �LODGE $55 �b-ll =TRAILERPARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 _ l�S _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 yCOMMON VIC. $60 � _WHOLESALE $80 — —RES[D.KITCHEN $80 � RETAIL SERVICE: �. LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# . <SOsy.ft. $50 >25,OOOsq.R. $285 VENDING-FOOD $25 �. =<25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $ll0 �. NAME CHANGE: $15 � AMOUNT DUE _ $ `�`�O .o J � *•***PLEASE TURN OVER AND COMPLETE 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 WORK�R'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 permits. PLEASE CHECK APPROPRIATELY IF PAID: I YES N� ' 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 terxn 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 i 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 I Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. 4 POOLS 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 are 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 standazd plate count by a State certified lab, and submitted to the Health Deparhnent tlu�ee (3) days priar to opening, and quarterly thereafter. j POOL CLOSING: Every outdoor in ground swi�nlrtingpae� *h �tra�ned 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 Departxnent by filing the F requued Temporary Food Service Application form 72 hours prior to the catered event. These forms can be � obtained at the Health Deparhnent,or from the Town's website at www.yannouth.ma.us under Health Department, i 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 Departsnent. Failure to do so will result in the suspension ar revocation of your Frozen , Dessert Pernut until the above terms have been met. I OUTSIDE CAFES: 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 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, 2014. 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 TE PL I � '��' I. DATE: �</L " SIGNATURE: ' � ' PRINT NAME&TITLE: � Rev. 11/03/14 . ��, I I f � The Commonwealth ofMassachusetts ' Department of Industrial Accidents Office oflnvestigations ' I Congress Street, Suite 100 Boston, MA 02I14-20U www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Anulicant Information Please Print Legiblv Business/Organization Name: �N (� � �!1 ,U /�P�?' ��_ � Address:� �' �, � r ��2 �2-P1 � I Ciry/State/Zip:��.�ZOr��( i d/ � l)'I H- Phone#: J�6 �'' 3l0 0� - �� Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ Retail �2.� or part-time).* 6. ❑ RestaurantlBaz/Eating Establishment I am a sole proprietor or parmership 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 corporarion and its officers have exercised 9. ❑ Entertauunent their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organizarion,staffed by volunteers, I 1.❑ Health Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#I must also fill oui the section below showing the'v workexs'compeasation policy information. **If the coiporate officets have exempted themselves,but the corporation has otha employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that isproviding workers'compensation insurance for my emp[oyees. Be[ow is thepolicy information. Inswance Company Name: Inswer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penakies of a fine up to $1,500.00 and/or one-yeaz 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 Investigations of the DIA for insurance coverage verificarion. Ido hereby certify,under thepa' s andpenalties ofperjury thal the information provided abave is bue and correct. Si ature: Date: Phone#: � '—J / O�cial use only. Do not write in this area,to be compfeted by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of HealtL 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia