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Home My WebLink AboutApplication and WC "4 `- ' y`Pa2T Vct_c.�kGE .�D1�-� TOWN OF YARMOUTS B4ARD OF HEALTH _ _., APPLICAITON FOIt LTCENSElPE 2!3 _ � �.' ' ' x�"'°r�-� ��...+� �� *Please comp�ete form and attach a11 necessary docur�nent��j�_ er�5 2009.% � � Fai�ure to do sa wi11 result in the return af your appt�cation pac, et. _ ,y,.� , _ _.. . . Yarmouthport Viilage Store NAME OF ESTABLISHMENT:� � 330 Main St. �2�--6�} TEL. # S�5-3��oZ� LOCA'TION ADDRESS: Yarmouth Port, MA 02675 MA.ILING AADRESS: ;, UWNER NAME: Yt, a� 4h+�+ 1� �Y/� F or S - CORPORATION NAME APPLIC ): 'v o,�n �' e -t MANAGER'S NAME: � iv�t L. # ,��"�3�?r-�� MAILING ADDRESS: a lwve POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated �' Paol Operator(s) and attacl�a copy o#'the certificati�nto xhi�_f4�.—_ 1. 2, � Pool pperators must list a minimum of two emp loyees currently certified in basic water safety,standard First Aid and Com�nunity Card.iapulmonary 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. , I i FOOD PROTECTION�vIANAGERS - CERTIFICATIONS: ' All food service establishments are required to have at least one full-time employee who is ccrtified as a Faod � 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 wiU nat use past years'records. � You mu rovide ne copies and maintain a file at your establishment. � 1. �hv� �v�v1 2. PERSON IN CHARGE: _ _ -- - __ - _�_ __—_t __ ___ -- - - _ _ _ _ _ Each fo establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. '�ti� 1 ',v o►�1 � 2. � i HEIMLICH CERTIFICATIQNS: i All food service establishments with 2S seats or more must have at least one employee trained in the Heiunlich k Maneuver on the premises at all times. Please list yow employees trained in anti-choking procedures below and � attach copies of employee certificarions to this form. The Health Department will not use past years' records. ; You must provide aew copies and maintain a file at your place of business. ; _ _ _ � 1. �. � 3. _ 4. � RESTAURANT SEAT'ING: TOTAL# OFF�CE USE ONLY LOIIGING: LIC�TTSE REQUIRED �EE PERMIT# LICENSE.REQUTRED FEE PERMIT# LJCENS�REQUIRED FEE PERMIT# .,,rBBcB $55 ,,_CA$IN $55 � _,,,MOTEL $55 11QN $55 �CAMP _ $55 �SWIMMINGPOOL $80ea. �,LODGE $55 �TRAII,ER PARK $105 _ , ,WI3IRI,POOL $80ea. FOOD SERVICE: LICENS�REQUIRED FEE PERMIT# LIC�NSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 S�ATS S$5 �a'(�7 _CONTINENTAI, �35 �NON-PROFIT $30 >100 SEATS $160 COMMON VIC. $60 �WHOLESALE $80 RETAQ.5ERVICE: —RESID.KITCHEN $80 � i LIGEN'SE REQUIRED-FEE -PERMtT# LIGENSE REQtJIRED FEE PERMIT# LIC£NSE REQUIRED FEE PERMIT# ' �<50 sq.ft. $SO >25,000 sq.ft. �225 � �VENDING-F40D $25 ,,,�Q5,000sq.ft. $80 -O`�Z ._FROZENDESSERT �40 �TOBACCO $55 �e�Z � NAME GHANGE: $is AMOUNT DUE = S 220.o0 **"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"*" � � � :._o �v ADMINISTRATION Under Chapter 152, S�ection 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or pernut to operate a business if a persan or company does not have a Certificate of Worker's Campensation Insura�ce. THE ATTACHED STATE Wo►1tKER'S COMFENSATION Il�TSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR �WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal ar issuance of your pennits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS A1�TD OTHER LODGING ESTABLLSHMCNTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy, ordinaril�►and customarily associated with motel and hotsi use. Transient accupants must have and be able to demonstrate that they maintain a principal p}a�ce 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 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 ha.ve been closed for the season musk be imsp� by the Health Department�prior to opening. Contact the Health Department to schedule the inspectian th[�e(3)days pnor to openuig.PLEA.SE NOTE:People are NOT allowed to sit m the pool azea untii the poOl has be�n��d and opened. POOL WATER TESTIl�TG: 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 opeiring, aad quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming paol must be drained or covexed within seven(7)days of closin�. FOOD SERVICE CATERTNG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temparary Food Service Applica.tion form 72 hours priar to the catered event. These forms can be obtained at the Health Department. FRUZEN DESSERTS: _ _ Frozen desserts must be tested on a monthly basis by a State certified lab. Test resu�ts must be sant to the Health Department. Failure to do so wili resu�t in the susp�nnsion 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 Board ofHealth. OUTDOOR COOKIl�TG: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishmept is rohibited.__ NOTICE:Permits run annually&om 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.TTY TO RETURN THE CQMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 20Q9. ALL RENOVATTONS TO ANY FOOD ESTABLIS , MOTEL OR POO�. (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND P OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ SITE PLAN. DATE: <( �'� � ' SIGNATURE: PRINT NAME&TITLE: `v A� 09l25/09 w .. . " , � The Commonwealtk of Massachusetts Department of Indust�za!Accidents �� 640 Washington Street, 7�h Floor ' Boston,Mas� 02111 Worlcers'Comp�eeaatioa iesorance Afli�vit:Building/Plembing/Ek�clricat Coatractors t . �: � "�a � �'a�e� � vl� �1� . (� � _an v�JoJ �-- �1� �. �s: �� V�� -- . (L�- b If� �n� �� .w-oN� a�. �- s«��: � : � . a�-6��' hone 0 -3b� — 60 work e location full address. ` �Y�l� \ ❑ I am a homeowner perfomring all work myseif. Project Type: ❑New Constructi�QRemodel ❑ I am a sole ProPnetor and have no one working in anY caP�ih'- ❑Beuiding Addition �I am an anployer providing wozkeis'compensati�for my empby�s wodcing on this job. _ -�--,_- _ _ �� _.. __ _ _ -- -- -_ _ ___-.- ;�-- - - comoanv aame: iddKss• citv: o4uae�: 3as c°' / / .:-._ , ...�. . '_..;.. :-:c, T 4.';.=-� 13?'f:" . :':.. ..'. .. '� .-., +i..�'.y"`G�c ..<Fr:�, r..P,a=..a&3 .-'v7..-+e.�.{�1'.�3...� ` � .'i ❑ I am a sole propne#or,ge■e�al c�tcactor,or homeewwer(circte one)and have hired the ca�actors listed below who have} the fotlowing warkexs'cotnpensation policesr � uomo�o i�amc: . j addreas: : cit� - ' ��, � i�atioe to. , � ,,:�, :�r- I .. , _ < - ..�;z_ ,�:. �.i��t,.� �> �Y Noe: addreu; � � , nka�e f�- . . � - - _ — � __ .. : ' ., : _ — -- > � = = -x- � . :r ,. ��i '��.# .��,.b=^�,:yr.,�� `��. "u_�.�'�, � Fa�e b sx.re as req.ired,�der secu..2Se►.f Mrd,l�m kad a nie�.�itl...ca6�ioai pm16a�a 5e�a s1,�li aNhr�� i�' as wer b dH pe�dtla h tre��ta 3TOt WORK ORDBA ud a Aee dS1A0.Y�a�ap�t ie.1�td th�a «�y.ruu. r��,�aea��omo�.r�.�u.�.r�nu��+�m�w.. I i t da keneby�eraly d. �e�s.wt pewdd��ofPali+�+7'aier ara lx,fer�r�aree�,g�.boae tc�re m�d { � ` �� Il z�- � i � Pr;nc name �4tv� \ ive'�ti � P�,�� -3 � � I .ffidal.x.nly ao.�t.mite�tW.are.t�n��9.�Y��t�.�al,. i city er t�n: �* I�seiais.�� - I ❑�ed[��1e re�pstx b req�f�ed �� a�d ��, ��;� P� (��7)