The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � � � ��Y Ca-v�.�a�N� • � ^� � TOWN OF YARMOUTH BOARD OF HEALTH r � . �� APPLICATION FOR LICENSEl�E�IT=�2� � � � �... 1 Mp � * Please complete form and attach all neces oCt��n��by ` ce er7f2��02011 Failure to do so will result in the re�rn cl€ytlut application p et�, ,1 ., , ,;;,.�� ESTABLISHMENT NAME: ^ �SC v. TAX ID: LOCATION ADDRESS: wi TEL.#: G " MAILING ADDRESS: E e� e, 7 OWNEA NAME: � ' CORPORATION NAME IF APP ICABLE : I�o s a, c a T„� MANAGER'SNAME: �� < <y TEL.#: aF / � MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool O�e�•ator(s and attach a copy of the ce ifcation to this form. 1. 1� . -�-� � 4e � �4 �' rc � z. Pool operators must list a minunum of two employees currently certified in basic water safety, standard First Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' rewrds. You must provide new copies and maintain a tle at your place of business. 1. � � a� �a (' �� 2. 1'T� l1��aC1'c��( 3. a � �_sC� � 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: 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 Seivice Establislunents, 105 CMR 590.000. Please attach copies of cei�tification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a 51e at your establishment. i. 2, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site durine hours of operation. 1. 2_ HEIMLICH CERTIFICATIONS: Ali food seivice 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 yom• employees tranied in anti-chokmg procedw•es below and attach copies of employee certifications to this foi7n. The Health Department will not use past years' records. You must provide new copies and maintain a fi(e at your place of business. 1. Z, 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PE&'�III'# LICENSE REQUIItED FEE PER�4I7� LICENSE REQUIRED FEE PER�IIT� _B&B 555 _CABIN S55 1D10TEL $55 _INN S55 _CAMP Si� LSIVIbLbDNGPOOL S80ex. � _LODGE S55 `TRAII.ERPARK SIO� ��L'HIRLPOOL S80ea. FOOD SER\7CE: LICENSE REQL9RED FEE PER�fI?= L[CENSE REQUIRED FEE PER�4IT# L[CENSE REQUIRED FEE PE&�SII'n _0-100 SEATS S85 �CONI'INENI'AL S35 NON-PROFII S30 _>I00 SEA7S SI60 _CO'VLYSON VIC. S60 R'HOLESALE S80 RE'I.�IL SER�'ICE: —RESID.KI7CHEN S30 L[CENSE REQUIKED FEE PER'btI'I# LICENSE REQUIRED FEE PERb11T- LICENSE REQUIRED FEE PERbIII'� _<SO sq1t. S50 _>'_S,OOO sq.ft. 5225 VENDING-FOOD S25 _<25,OOOsq.ft S80 _FROZENDESSERI" S40 TOBACCO 555 �a�7E c��cE: sis AMOUNT DUE _ $ ��O.QQ "**`*pLEASE 1'tiR\OVER A\D COYIPLE'IE OTHER SIDE OF FOR\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 STA'I`E 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 pernilts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIEN'I'OCCUPANCI': For purposes ofthe 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 ofresidence 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 coilection 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 swimrrung,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health DepaRment to schedule the inspection three(3)days pnor to opening. PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected I 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 swimming pool must be drained or covered within seven(7)days of i ciosing. � FOOD SERVICE ;I 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 inspechon 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.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: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Hea1th. OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishmem 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 I5, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APP OVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY R A S P `��G%'(� DATE: �j '� � � � SIGNATURE: , PRINTNAD4E&TITLE: i q„c ��+cic- � (�CC7 - to ua�io i � . ,p� I ` �\ The Commonweahh ofAfassachusetts Depa�hnent ojlndustria(Accidents N�felN� 600 Washington Street, 7`"Floor Boston,Moss, 02111 Workers'CompensaHoa Irooraace Aflidavk: ge��d��g/plembia�/Ekctrieil Coatractors� � name• • � • � O�4 �hY� " . ��s• _t �7 �4c �_� ci c�i�. �r I11��_—_—.sm4: � �_—_ zio'�lX.L�� ohonr X 10 6"l 9�f�/ �` 3 work site locatioo fiill address: - . .. �❑ [am a homeown�perfoiming all work myself. � Projec[Type: �New Conshuction QRemodel I am a wle proprietor azd have no one working in any capacity, �Bwlding Addition ❑ I arn an employer providing workess'compensation for my employees working on this job. con �ne: ad�mr eIry- ol�aee M � cp, N ❑ [am a sole proprietor,Beaeral eo�tracMr,or homeew�r(cirde onel and have hired the contraccas listed below who have the foilowing workers'compen,gation polices: addras• citY' nYa�e N in see ee. I � addres�c �Y• o�e�s N is� I AWelY�rl�Yrlhmrrrr K � �' F�Bve b aame ure�de n reqdrM��dv SetliN 2SA d M(:L 132 cu Ind b IYe 1�w�� . . . . . i °�Yti�+'iepHia��nt n weY a dH peuqb I�tse fir�eta STO�WORK ORDBR ad�eee MSIOLM�d��f��e 4 b f1,3N.M aWr �� npy dH6+raleweY my he f�rwarMd b tAe OQiee st�tbll�o ef He DIA far e��erade verietalM. r��ae. 1�de�W W�t a i !do Aereby cntll d�patw u1 fajonnmrion pro�ided aboae tr arre wd cemrt �� Signatum �,i `'� narc _ '�i^��—// � ! Print na+ue l C �l r 1 �C) '�J 7' /2.�}� ,. Phone M 6 e�l ose ooty M ea w�ife In thM a'ea Is be . . . . . i,� �aplefed by dly or 1�wp u�e� �cNy or bwp: ��g ❑Boidiei DR��et � I ❑ehedc HlmnaW h rt�peme b d�ed � QlJces ��.. � n� . .�,�� . oewet penoa: cR-.�+a s�mm� P`o.e N• �� R+��at I