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Home My WebLink AboutApplication and WC a- TOWN OF YARMOUTH BOARD OF HEALTH _� ,� _: o � �� APPLICATION FOR LICENSE/PERL�I�� „p1, .��'�0 d�� d� � * Please complete form and attach all necessary docui�ne '- �eeembe l5 ��yl� � �O 11 Failure to do so will result in the return of your applicarion pac • H�LTH DEPI�. ESTABLISHMENT NAME: �cCiP COd SU02'C �7J�.� TAx m: ��'�� LocaTiorr:wD�ss: �.R Mac�n � �2�a,�c w�t�ccro.sNc,�nAou,r�'rsL.#: �c'�-'1�5-Fc►ib MAILING ADDRESS: � OWNER NAME: C�� '3Yc�0 l� CORPORATION NAME(IF APPLICABLE):C� (9cI �CAe_x �S{�e� T.r�. MANAGER'S NAME: G �3iZ0 \:� TEL.#: SOg-�l�1S-�110_ MAII.ING ADDRESS: 2�ait1 �t R� �4s We5! V.�vmu�Mc1� M►°� (j2h'1� 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 Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Healt6 Department will not use past years'records. You must provide new copies and maintain a f'�le at your establishmenw 1. C' �� ►2U l,. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. ��+'�A �3i00 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 all times. Please list your employees uained 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�le at your place of business. �. 'F�x�ca KuK Orlevno, 2. Gva�nd Bcao l.� 3. c� 4. RESTAURANT SEATING: TOTAL# O�J OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _C.4iVfI' $5� _S�VIMMINGPt�OL $80ea _LODGE $55 _TRAII FR ppRK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100SEATS $85 _CONTINENTAL $35 _NON-PROFTT $30 �>]00SEATS $160 �a"Q✓lo �COMMONVIC. $60 .�� _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 - _TOBACCO $95 NAME CHANGE: $IS AMOUNT DiJE _ $ �-2C'•o0 •'�•**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 pernut 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 �� OR WORKER'S COMP. AFFIDAVTI' 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: YES ` NO MOTELS �LP3D OTHER L�.3DGi:�1�ES�'ABLISI�YIEEN'T3 . TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be I 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 contimious 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. j POOLS 'i POOL OPEIVING: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 De�amnent to schedule the inspection three(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to sit m 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: i 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. CA1'ERING POLICY: An one who caters within the Town of Yarmouth must noti the Yazmouth Health De artment b filin the required Temporary Food Service Application form 72 hours prior to the catered eventp These forYms 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 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: �.tts�saf€s-{�.s.��4�eers�et�-�+ith-waiter/waiEress sRa�vice}m�ist have prior apgroval fror:�ths Board af�ealth. OUTDOOR COOKING: 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 REQUIl2ED FEE(S) BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHMEN'I', MOTEL OR POOL (i.e., PAIN'I'ING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUII2E A STl'E PLAN. I DATE: �1�I/d�11 SIGNATURE: ��``''�- �'-`^� � L- PRINT NAME& TITLE: GJd'nq �U'�D I t — �VIeYk74er Aev.10/25/11 �'.. � � The Commonwealth of Massachusetts DePaK�neet of Indastrial Accidenls N�fClN�dNs 600 Washing7on Street, �"Flaor I Boston,Mass. 011ll Worlcers'Compensatioe lusoraaee Atfldavif:" �idirmatlw• Mdr PRINf led6h . name: �'NPrr� �TK�O l,� —�.,��Ttrer n{ Ca11,Q (0(��r �� TanC '. addtcss: 1 Z.�S Ma�CI_�'} ------._ .-- ��w west varc�.�i Sm«: M A �o: n2e�'� on�a ��Fs—71S—$�) wort sih�ocation rrou aadressl: ❑ 1 am a homeowner performing all woik myself. ❑ I am a sole propridor and have eo one wocking in any capacity. . � �J/ f am an employer providing worke�s'compensation for my employees wolking on ihis job. eom�vdne: `�f�i��_;�}��1""" :t�. _ ..-�. : �:_>: , . _ _�.�..;� aa�rw: 225� �'�� -. �ya��xx3�'r� M`l3 �.: S�Ts--1"1S�\lb t..�.«�..A�c�ated y'I��y��r�e��a�E lv��acltia��tS o.n�.x Rw[ 1�D55 y SO�2�11 ❑ I am a sole pr�op��gn' las ea�trx r,t6'�or 4�eoweer(coc/i o+u)aed 6ave hired the conuxtas listad below w6o have We following workers'compenvation polices: � . � � ceoeuv�me• addresr citv: oYa�e M: (eavaKe t0. notic�N � rn�ouv we: adA►e#f• tlts- oYa�e A� - ---_. _. .--- --- --- _. _. . _-- - - ._-�- — ---- [e�ea�ee ee. .._ _ . ... .. � - oalie�A .. _... . -- ,ur�r.i�rr.r r.r r.....� Fa9ve Y xeve e+naee s�eq�trd uds See7W 2SA dMGL 132 eu kad M t►e 4RwMW dah�Wl pe�Nln d��e R b 31.3KM uY�r o�e ynn'lepr6w�mt a��el a dH penitln Is t6e fir�Ka STO)WORK ORDBA W�6e 1S1M.N a da��pWt ee. t mdmhW tYtl• espy Ntlb MaOe-eN my be firw�rdid b the Omee e[IareWpWr d He DIA Ar t�w�e valOnW�. /do lYenby n�rndar nie pLu aw/9��olv�'I�rP tlYa Mt twforsdlon prevlle/obeae tf arr twd csrmt SiBnatum ��'71�j' '°_f,.� ti Dah —_�1�o/�� Prim name�� Pi��O �\ P6one M_�CS�TIS�� o�dd ox soly do eM wrke 4166 a�n a he w�PINW Aq dry'er bws s�chl . . � � . �_ �_ . n c(y x tewo:. . .. . . 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