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Home My WebLink AboutApplication and WCr ,— o�K.ER'Z ; d � TOWN OF YARMOUTH BOARD OF HE , � APPLICATION FOR LICENSE/PERMIT -� � � � � � � * Please complete form and attach a11 necessary documents by D em IS �0�� Failure to do so will result in the retum of your applicatio pa �t,. `��;��rE- e;_�r. ESTABLISHMENT NAME: � ON✓�i Ek Z �R2T5� ZONC TAX ID: � LOCATION ADDRESS:/'S 7 R�(028 w �ARM o�7'bf � �?l�3u�tCy�/g TEL#• �1- �75 -I� la MAILING ADDRESS: OWNERNAME: (`�SoN E� M�v.� CR��57��,q �C- r/Tzf�E�iaL9 CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: TEL.#: 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. 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 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. 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 Establishxnents, 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.��C.F-i�i J�✓ �7.4�LES 2. �� I�fC--i�2a �R�Biv'Pv'�-- --- -- Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. LL�PTc�N �^9GLES 2. �1i4QEN 1�/�7RA 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 file at your place of business. 1.C�r'si7'An/� F ��7ZfiC�P�'9�� 2. 3. 4. RESTAURANT SEATING: TOTAL# �L c OFFICE USE ONLY LODGING: LICENSE REQU[RED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � � _ B&B $55 _CABIN $55 _MOTEL $55 _INN $55 CAMP $55 _SWIMMING POOL $80ea_ � _LODGE $55 _'[RA[LERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-�100SEATS $85 �k �3-Iya _CONTINENTAL $35 NON-PROFIT $30 , >I00 SEATS $160 I COMMON VIC. $60 �l3-ai� _WHOLESALE $80 �� RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.ft. $50 >25,OOO�sq.ft. $225 _VENDING-FOOD $25 _ <25,000 sq.ft. $80 _FROZEN DESSERT S40 TOBACCO $95 NAMECHANGE: $15 AMOUNTDUE _ $ j�.5.00 � **""*PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM***** '� -� , - ', � � ADMINISTRATION e 152 Section 25C Subsection 6 the Town of Yarmouth is now re uired to hold issuance or renewal Under Chapt r , , > 4 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 CERT. OF INSURANCE ATTACHED j OR '� WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ', Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MO'FELS AND�THER LODGING ESTr4SLiS�iM�NTS : _ . TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be j limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. I 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 or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS ' POOL OPEPiING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department priar to opening. Contact the Health Department to schedule the inspection three(3)days � prior to opening.PLEASE NOTE: People are NOT allowed to srt m the pool azea unUl the pool has been inspected , and opened. I POOL WATER TESTING: The water must be tested far 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 Deparhnent 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.varmouth.ma.us under Health Department, 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 Deparhnent. 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: _Outsidecafes(ie. outdo4r_s�atingvuithwaiterizaraitresssei�uise�veprieF�ro�• . . . — 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 RESPONSIBILITl'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 I E PLAN. DATE:�I -p o�- o�-��3 SIGNATURE: PR1NT NAME& TITLE: Ds p�/ '' - � 9u^r�- Rev. 10/09/12 i � � . � The Commonwealth ofMassachusetts Department of Industrial Accidents � Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Le¢ibtv Business/OrganizationName: �� I`� 1�E'eZ '3"�11?i'fY �CJ/�!C 1 �e Address: �D✓�- 7 !S T �- � C^f�2 � V 7z �i''✓��j City/State/Zip: W�� ✓�iN�e>?7� Phone#: 'J`�� 7 � J� l� 1�rD Are you an emp►oyer?Clieck the appropriate box: _ Business Type_(require� 1.� I am a employer with o� employees(full and/ 5. Q Retail or part-time).* 6. ❑ RestauranUBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance requiredj 8• ❑Non-profit 3.❑ We aze a corporation and its officers have exercised 9. �Enter[ainment 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 ora nizarion,staffed by volunteers, 11.0 Health Caze with no employees. [No workers' comp. insurance req.] 12.0 Other *My applicant that checks box#1 must also fill out the section below showing thev workers'compensation policy infolmation. **If the corpomte officers have exempted[hemselves,but the corporation has other employees,a workers'compensa[ion policy is required and such an organi7afion should check box#L � . . . I am an emp[oyer that is providing workers'compensation insurance for my emp�loy"ee"s. Below is the poGcy infarmation. Insurance Company Name:�C C�.�j./Z � C� • � /fi'�/ 1 2�5� N� �!/J ' Insurer's Address: ►� o - �01C � F'7 /S�� city�srare✓ziP: �'.4�e Cf�2�0�L- y�-- �3 9�l S -- - o icy or e -ms:��`c.� ��t-�^�8 y� ' ai Date:--��-��:3 Attach a copy of the workers' compensation policy declaration page(showing the poticy aumber and espiration date). Failure to secure coverage as requued under Secfion 25A of MGL c. 152 can lead to the imposition of criminal penalties 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 forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce nde e pains and pena[ties af pery'ury that the injormation provided above is true and correct. Sienature: Date� D 1 - 0.2 - �/ Phone#: Official use only. Do not write in this area,to be completed by city or town o�cial City or Town:yA-Qp,(plT'Tkl Permit/License# Iss ' ' cle one): 1. ard of Health 2 Building Department 3. City/Town Clerk 4.Licensing Baard 5.Selectmen's Office 6. ContactPersan: Phone#: �B-,�`i'S c3c�3/ ��aC/� � . . . . www.mass.gov/dia . . . �