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Home My WebLink AboutApplication and WC � Towx oF Yax�vrouTs sa�xn oF� trx: '�%�`�C�" � . APPLICATION FOR LICENSE/PERMTI'-20 ��<� _ �: �; JUL 0 8 2010 *Please complete form and attach all necessazy dacum ��ce� .,��2�AA.��"�'. ;�'ailure to do so will result in the return af your application p ----�---- �.,.,�.�..��..... NAME OF ESTA�iLISH��IENT: Gv� !' Q ��, TEL. #��/� � LOCATION ADDRESS: C ' MAILING ADDRES�: C ' OWNER NAME: �-' FE or CORPORA.TION NAME (IF APPLICA E): � �` MANAGER'S NAME; ' TEL. # — � MAILIlVG t�DDRESS: C - � _,..�.�._�....�.��_.�,_.�_.. POOL CERTTFICATIONS: The pool supervisor must be certified as a Pool pperator,as reqaired by State law. Please list the designated � Pool_Operator(s) and at�h a c��of the certificarion to this form. __ ___ __ __ _ 1. 2. , ; Paol operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Commwnity Cardiopulmonary Resuscitarion(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. �. l. 2, 3. 4. ��i r�i�i��n��.�� FOOD PROTECTION�v1ANAGERS - 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 ta this applicatian. The Health Department will not use past years'records. You mnst provide new copies and maiptain a file at your establishment. 1• ? l 2. I PERSON IN CHARGE: __ — --- __ _ __- - — _ — - Each food establishment must have at least one Persem In Charge (PIC) on site during hours of operation. � 1 2 ' HEIMLICH CERTIFICATIONS: All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all rimes. Please list your erYployees trained in anri-chokuig procedures below and attach copies of employee certificarions to this form. The Health Department will aot use past years' records. You must provide new copies and maintain a file at your place of business. 1. � 3. 4. _ RESTAURA.NT SEATING: TOTAL# OFFICE USE ONLY � LODGING: LIC�NSE REQUIRED FEE pERMIT# LICENSE REQUIRED FE$ PERMIT# LICENS�REQUIRED FEE PERMIT# � _B&B $55 CABIN $55 r,,,MOTEL $55 i — I �1NN $55 _�� CAMp $55 �SWIMMII�IG POOL $$Oea. �LODGE $55 ID�6�d �TR,AII,ERPARK $105 _WHIIt�,POOL $80ea. FOOD SERVICE: LICENSL REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIR�D FEE PERMIT# �0-100 S�ATS $85 0� gs _GONTINENTAL $35 TNON-PROFIT $30 ' >100 SEATS $160 I COMMON VIC. $60 ��Q�� WHOLESALE $80 RETAII.SERV'ICE: —RESID.KITCHEN $80 LIGBNSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMTT# _,<50 sq.ft. �54 >25,000 sq.R. �225 ____VENb1NG-�40D $25 „_,_�25,000 sq.ft. $80 _FRQZ�Ti DESSERT $40 TTOBACCO $55 NAMECHANGE: $is AMOUNTDUE = S a-o6.00 "**"«PLEASE TU12N OVER AND COMPLETE OTHER SIDE OF FORM�**** - � .. � � ADMINISTRATION � � ; ; , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now require�to hold issuance or renewal ' of any license or pennit to operate a business if a person or company does not ha.v� a Certifica.te of Worker's ; Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE . � AFFIDAVIT MUST BE COMPLEI"ED AND SIGNED, OR � �. -1 , � 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. PLEAS�CHECK � APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LUDGING ESTABLISHMEN�`S TRANSIENT OCCUPANCY: For purposes of the limitations of Motei or Hotel use,Transient accupancy sha11 be � limitEd to the temporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use. � Transient occupants must have and be able to demonsixate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 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)rnonth period. Use of a guest unit as a residence or dwelling unit shaU 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 generaUy be considcred Transieirt. _ , POOLS _ _ � POOL OPENING: All swimming,wading and whirlpools which ha.ve b�en closed for tlae season must be inspected ; by the Health Department prior to openin�. Contact the Health Department to schedule the inspection three(�)days � pnor to opeiung.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected � and opened. j POOL WATER TESTIl�TG: The water must be tested for pseudomanas,tatal coliform and standard p�e count � by a State certified lab, and submitted to the Health Department three (3) days prior to openin�, and quarterly thereafter. _ POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. F40D S�RVICE CATERING FOLICY• � Anyone whv caters within the Town of Yarmouth must notify the Yarmouth Health D+epartmem 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the�-Iealth Department. Failure to do so will result in the suspension or revocation of your Frazen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have priar approval from the Board ofHealth. OUTDOOR CUOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmart is prohibited. N4TICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILY�'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POO�. (i.e., PATN'I'ING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI"T'E PLAN. DATE: �� SIGNATURE: � PRINT NAME&TITLE: / � U9/25/09 � �9� - ,"'"'� � � --- - � , f ' � �\ The Commonwealth of Massachusetts s � ,. Department of Indusd•ia!Accidents Nllfri�fi� 600 Washington Street, 7`�'Floar Boston,Mas� OZlll � Workers'Compeess�tion I�sara�ce Atfidavih Buildieg/Plembieg/Electrical Contractors Anoliea�rt_ia�et#li�. p'�re pRIl�IT le�ibl� �_�,�� '� r��-�� - �- n �, � address: ci v � s te• zi : e -- � vwrk site location ffull addressY. ` �( I am a 6omeowner perfom�ing all work myself. Project Type: ❑New Constivcti�QRemodel �[�''I am a sole proprietor and have no one working in any capacity. Q Building Addition ❑ I am an einployer providing workers'eompensation f�my employees wodcing on this job. _ _ __-_ _-- �, � - - ____ _ _ comtnav�ame: --- addreas- : clh�: uitaae#: : Lu ca ;�:.. _„_. _�:,.;. vz,:->' . n v-:�•a ::.._ ,. ..-,-�: ::.�+ .. ;��.;. .,_,,:. ..:,�.� <.;:.�h, . .. �:r.a ,""vx.:."'�`-...a�� :•��..'�43 [� I am a sole proprietor,g�eral coatractor,or�omeewner(cirde one)and have lured the coniiacWts listed below who have the following warke.rs'compeosation polices: ' o_�tnwv�c• addresr dtr• okoae�. � _ i�a�a�oe co.. �- , , , � � �'' , , . _ . _,� . ,_, .�.:::= ��:�`.�`��t.- �Y tame: s�u: s�: ��• — - --� - - - ,� . --. .: . _ — __ .- - __ � -- -, , _ :• :,;.:: °. � . .,, . , . . . .. . ,-,:, ..,.:�� . ' . -...:> . .�t ,t..6`+:' r»`��,.`i�-��.'-.�`' ;�'rr..r3.+...'t'�s�'.{i"�'� '"_;:""...e�°�y'�!�*':R'�-v"'"•.,�°m_x��' .,<:,:�� -. 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