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Home My WebLink AboutApplication and WC . � d TOWN OF YARMOUTH BOARD OF HEALT�I, � E �� : e� � APPLICATION FOR LICENSE/P�� '� 0 �y ` (��u O P L O i� * Please complete form and attach all necess a r�oc b ecem er flEPT. Failure to do so will result in the return o your applicauon pa . ESTABLISHIVIENT NAME� �sea �TN„� S`.sb��ta�oT ID� � �� L,OCATIONADDRESS: ot7�-c o2 �o etM+o TEL.#: - - / Se� MAII.ING ADDRE S: i 1 a m r 75 7 OWNER NAME: + ac.� 4�r c � CORPORATION N (IF AP LICABLE : S oa �T�C • MANAGER'S NAME� ��a��'�a r•l- � TEL.#: o�r -397 - /�3 7 MAILING ADDRESS: t o� � ' v� �17� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poo Operato (s) and attach a copy of the ertif'icauon to this forrn. _ 1. � �C�'�4e.` �a�'!`C��!> 2, Pool operators must list a miniinum of two employees currently cert�ed 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 Department will not use past years' records. You must provide new copies and maintain a t"�e at your place of business. , p 1. I�I�C�at�` �4f « ` ♦ 2. G�e'`C� �a'c fc,1 T1 3. 4. 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 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 establishmenG 1. 2. PERSON II�I CET.ARG� _ __ __ _._ . _ -- --— — -- _ --- _ Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. 2. HEIlvII.ICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heixnlich 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 REQUIItED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 � MOTEL $55 � � � _INN $55 _CAMP $55 �SWIMMINGPOOL $SOea.�I'/a'D`�S _LODGE $55 _TRAILERPARK $105 _WHIRi.POOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _Od00SEA1'S $85 �CONTINENTAL $35 � �YS _NON-PROFIT $30 _>100SEAT5 $160 _COMMONVIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIl2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.ft. $50 _>25,OOOsq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CAANGE: $15 AMOiJNT DLTE _ $ � 70� 00 *'"*s*PLEASE TURN OVER AND COMPLETE OTIIER SIDE OF FORM'x��• , , 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 ATTACI�ED STATE WORKER'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. PL.EASE CHECK � APPROPRIATELY IF PAID: I YES� NO MOTELS AI+ID OTHER L�DDGINi�ESTABLISHrIENTS I I TRANSIENT OCCUPANCY: For purposes of the limitations of Motel 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 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departrnent prior to opening. Contact the Health Department to schedule the inspection three(3)days i pnor to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pool has been inspected f 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. I POOL CLOSING: Every outdoor in ground swimm;ng 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. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by £iling 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. I FROZEN DESSERTS: II Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results I submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen i Dessert Permit until the above terms have been met. OUTSIDE CAFES: E)utside��€es(i.e.;dui�eer sea±u!gwith waiterFwaitress sarvie�,mus.?4avep�iora�al€roarthe Bear��I�..akth. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. � NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETCJ, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE A STf P DATE: / / SIGNATURE: PRINT NAME&T1TLE: � a �x f �- � s c -��, a�.�azsn� • �\ The Coramonwealth of Massachusetts Departnrent ojlndusttial Accidents 1r�eaa�d�s 600 Was6ington StrM, �"'Floar Boston,Mosc. 02111 Worlcers'Compeesatio�imarasee Affldavk:� � � � � - � ... . . � � name: �t �--5 Cc.�t'_�vt h � � p� � address: _�� o T _��.� .. ciN J G � G�/'�10� sfatc � � I� zio• �K4G.Y ohone M ��i.J��ec.S�! wotk sire tocation truu aa�hessl: . �I�a 6omeownix pecfoiming all work myself. I arn a sole proFxietor aod 6ave no one wocking io any ppecity. ❑ [am an empbyer providing wa�kkecs'compeaaati�Cor my�ployees wodcing a�t6is job. � �`F',-- •' --r-. -��..'._ _ �_.. ._ ._... _ � : . ._.. _ . _. .... c000av�me' � r ' - • .v - -:- -- - - ad�as• �'• d�aee k• . (na�ta�u e�. oelk►p � ❑ i am a sole proprietor,gneral eeeMetor,or homeowoer(crrde owe)and have hirod ihe coehacWca listed below who have the following wake�compensation policea srt�mv�u�e• . addresc �s' nYa�e k� (eaqa�ee co. oalkr N . �Yse: �• �" oia�e!F _ _.. ._ - --- -_— - ..�_.- —_. -- —_. -- --- Iinaa�u cs. �p..� � � �rrrrrrr.rr..w.s Fdlte b aeewe w.vase o.ayree o+v se�1w ssA.tMCL ts2 m rw a�re I�ynMl.�.ra+.rd pewn.t■Ae y a s►3M:M aw.r �1��*'�mP��a�u wd n dH pmltln I�16e fir�Ka SI'Or WOAIC ORDBR atl�me dSIN.M�Ary apWt�e. !ode�ud IYt• cepy af Nh ft�h�e�t s�r 6e finnMtd b tAe O�a d1WeM1�IMr tlUe DIA far p�tlase v�ntlM. /bAarlyeerYfyr � r �p.k.. v�di �l i �`r Bo,��asetrao�err��acs..�c �� ia-s-ao� Priotname � ocE. ar�'e� •� � .. . Phonek ' J`^��*�S`r�.. �� - . � a16ew.x.wy ao eat mrm d tYx■.r�u ae aooWeled h cllr.r wws.mew � . � . .. ... , �. dy or bwn. . . ... . ��ry ❑�� . '�,. ❑ehed Nimoedhee napeme b�eq�6ed ❑'�� . ,��. 03diemes's Ofece �lleM�D�t�t . nahctpenoc Py�M� � tmma s�mao� �