HomeMy WebLinkAboutApplication and WCC`� , � �E�� cA�
��� TOWN OF YARMOUTH BOARD OF HEALTI-�� �� � "" � -
APPLICATION FOR LICENSE/PE$�'I'k�0 I ' ' � ^ '
�`
� * Please complete form and attach all necessary-tlocu�e� der 1��0�2� 2013 �`�` '
Failure to do so will result in the return of your application pac et.,, ,.
ESTABLISHMENT NAME: G� �2'�_ � TAX ID: ��
LOCATIONADDRESS: .� 't� 2,� w� `l�/YkRr� TEL.#: �,7�� 77/-3�/yy
iMAILING ADDRESS:
I OWNERNAME: —TOIi� i5%e//
i CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL.#:
i 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 atta.ch a copy of the_certificati4n to tlus fo�rr.- _
I 1. . 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Deparhnent will not use past years' records. You must
provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
I FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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 ofcertification to this application. The Health Department will not use past years'records.
� You must provide new copies and maintain a file at your establishment.
i �. �i�� �������� 2. �:� k��s
'I - -FER� N ii �`anUE: - -- ——-_ <- - - _
Each food establislunent must have at least one Person In Charge(PIC) on site during hours of operation.
1. 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-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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
� OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
i B&B $55 CABIN $55 MOTEL $55
_INN $55 _CAMP $55 _SW[MM1NG POGL $80ea
LODGE $55 TRAILERPARK $l05 WHIRLPOOL $80ea.
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I I 0-100SEATS $85 � �p� _CONTINENTAL $35 _NON-PROFIT $30
� >100 SEATS $160 COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE: � —RESID.K[TCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE �PERMIT# LICENSE REQUIRED FEE PERMIT# �
_<SOsq.ft. $50 >25,OOOsq.ft. $225 _VENDING-.FOOD $25 .
<25,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ $S•00 ��
****'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'****
,
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 INSi7RANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth tases and liens must be paid prio o renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTEL� ANb OTI3ER LODGING�STABLI9HME�TTS - - ' -- - ---
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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
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 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 standazd 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 Deparhnent 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.yazrnouth.ma.us under Health Departrnent,
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:
Outside cafes(i.e.,outdoor seatin�with waiter/waitr�ss service),must haue}�rier�pg�e�al fr tii. - -
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail ar food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 3 L 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 UIRE A SITE PLAN.
DATE: I I�,O� �� SIGNATURE: S�0 ��
� PxrrrT NaME & TITLE: `��li �. �('iS�II ���(�
Rev. 10/09/12
� g
� � The Commonwealth ofMassachusetts
Department oflndustrialAccidents
'' - Offace of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-20I7
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
j Annlicant Information Please Print Le¢iblv
JBusiness/Organization Name: l ,� , C� ( �/,K(��
� Address: rj� �/1� `�, '�
,
City/State/Zip: Phone#: —
�_ _. ._ . .Areyouanemployer?CheckY4eap,propriafe�hex:. _....--. Busine�s�'YPe-�re9uU'ea!): -. . �. - . - . .— _ ..
1.❑ I am a employer with employees(fiatl and! 5. ❑ Retail
2.�r part-time).* 6. ❑ RestaurantBarBating Establishment
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.❑ W e aze a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per a 152, §1(4),and we have I 0.❑Manufacturing
�� no employees. [No workers' comp. insura�ce required]* ll.�Health Caze
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑Other
( *My applicant that checks box#I must also fill out the section below showing the'v workers'compensation policy information.
**If the corporzte officers have exemp[ed themselvu,but the corporation has other employees,a workers'wmpensation policy is required and such an
iorgani�atlon shauld check box#1.
I am an emp[oyer that is providing workers'compensation insurance for my employees. Be[ow is the policy information.
Insurance Company Name:
�
� Inswer's Address:
I City/State/Zip:
�- - __.FoTicy#or S�if-it��ti .�#`r -- -- - -- — _ - _ _��_�__
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$I,500.00 and/or one-yeaz imprisonment,as weli 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 verification.
I do hereby certify, der the pains penalties of perjury that the information provided above is true and correct.
� 3`�/ 3
Sienatur��,/�,/'�/�,,,,/ r� Date: T_ �
Phone#: �
Official use on[y. Do not write in this area,to be comp[eted by city or town o�ciaC
CiTy or Town: ��1�401T C� Permit/License#
Is ��circle one):
1 Board of Hea 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.
Contact Person: Phone#: �1Q"j�[s—��"� ?C�ZY 0
_
. . . _ . ... ww�v.mass.gCv!aia �