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HomeMy WebLinkAboutApplication and WC i ► TOWN OF YARMOUTH BOARD OF HEALT�H�� ��� ���'�"�� � � � '� � � APPLICATION FOR LICENSE/P ¢ 2 1� ° � 3 � _ � - �� � � � c�c 3 o zo�o � �� � ,N � A �' S r � * Please complete form and attach a11 necessar�dbcu �� � ' �ecem r I S 2010 Failure to do so will result in the return'=�yo `� application ac et. '_ �a_ ; " ESTABLISHMENT NAME: 13 TAX ID: LOCATION ADDRESS: � °' �1.-� Z.� �-�1,�..t . . s��:, -�-7 / �-a a f MAILING ADDRESS: S G�� OWNERNAME: n.t,���.�,!�. L-� �� t�l.c�l� - I�lt2ACt� I�—G CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: � • ��� TEL.#: MAILING ADDRESS: M�,"�,.,.v� ' POOL CERTffICATIONS: The pool supervisor must be certifed as a Pool Operator,as required by State laf�v. Please list the designated Pool Operator(s) and attach a copy of the certification to this fonn. ; 1. \�G4� 1'�- ��,r' 2. �.. �� Pool operators must list a muiimum of two employees cun ently certified in basic water safety, standard Fu•st Aid a.ud Commuiiity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department �vill not use past years' records. You must provide ne�r• copies and maintain a file at y�our place of business. 1. 2. ; 3. 4. �, � � � FOOD PROTECTION MANAGERS - CERTffICATIONS: i All food service establishments are requued to have at least one full-time emplayee who is certified as a Food ' Protection Manager, as defined ui the State Sa�utary Code for Food Seivice Establislunents, 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 establishment. ! 1. 2. PERSON iN CHARGE: Each food establislunent must have at least one Person In Charge (PIC} on site duruig hours of o�eration. 1. 2. HEIMLICH CERTIFICATIONS: ; All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich ' Maneuver on the premises at all tunes. Please list your employees trauied in anti-chokulg 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 vour place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERIVIIT.# LICENSE REQUIRED FEE PERi\�IT� LICENSE REQUIRED FEE PERIVIIT# ' _B&B S55 CABIN S5� �i�IOTEL S5� ��0�� INN S55 CAMP S» S�4LVL�4INGPOOL S80ea. LODGE S�� TRAII.ERPARK 510� «'HIRLPOOL S80ea. FOOD SER�'ICE: LICENSE REQL�IRED FEE PERVIIr� LICENSE REQLTIRED FEE PER�IIT� LICENSE REQUIRED FEE PER�ZIT� 0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 >100 SEATS S160 COVIMON VIC. S60 `��IOLESALE S80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�IIT� LICENSE REQUIRED FEE PER�III'# LICENSE REQUIRED FEE PER'�1IT� _<50 sq.t�. S50 _>25,000 sq.ft. S225 _VENDING-FOOD S2� _<2�,000 sq.ft. S80 _FROZEN DESSERT 540 _TOBACCO S» �A�TE CHA\GE: sis AMOUNT DUE _ $ 55.00 ***�*PLEASE TtiR\OVER A\D C013PLETE OI'HER SIDE OF FOR�T*"""** E � 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 STATE WORKER'S COMPENSAI'ION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED C� 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. PLEASE CHECK APPROPRIATELY IF PAID: �`�' . YES !�' NO MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 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)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 Depa.rtment prior to opening. Contact the Health Department to schedule the inspection three(3)days j pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area 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: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opemng. CATERING POLICY:, Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required f 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. OU�'SIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. r NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETCTRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR c TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ���1��� SIGNATURE: � PRINT NAME&TITLE: �-sq� , 10�06�10 v DEC. 30. 2010 1 ;50PM , NART INSURANCE � N0. 391 P. 1 � AcoRo,� �ERTIFICATE O� LIABiLITY INSURANCE ��`""�"' Pxoouc�e THIS C�R77F1CATE (S ISSUPA AS A MATCER.OF lNFORNIA710N HART{PISURANCE AGENCY, INC. ONLY AI� co��s NO RIGHTS u� THe Cr�T�ICATE 243 MAlN STREET �-��- � ��'� � �t �ND� DCTEaID OR ALTFR THE COVERA►GE AFFORDED BY THE POUClES BELOW. po aox 7ao BUZZARDS SAY, MA Q2532-0700 INSURERS AFFORDO�G GOVERAC3G f�WG 1F '"s� lrish vllsge Restaurant and Pub.1nC. �r�su�e�: GRAIVRE TA hl CE 23809 512 Main Stceei ��� West Yarmouth,MA 02673 � c �a q�IRER E GOVERAGES 7HE POLtC1ES bF IN3lJRIWCE LISTED BELOW MAVE 9�IV�SSUED Td TNE MiSUI�ED NMy1E0 ABOVE FOR'fNE POI.�CY PERIOD 1NDIC,�4'i�D.NOTIAATHSTANt}MtQ ANY REQUIREMENT,TERM OR CONDtriON OF ANY CON7RACT�!07HER AOCI�ENT Wfni RESPECT TO wMCrr TM�CER7�tCATE IeAY BE tS3UED OR MAY PERTAIN,7NE MISURANCE AFFORDED BY 7HE pOLICIES DESCRIBED M�R�V IS$U9JEG7 TO Atl Tl1E TER1N8,�(CLt1S10ti3 MID CONDRIONS OF SUqi Ppi,IC1ES.AGGREGATE LMrf$9H01NN MAY HAVE B6EN REDI}CHO BY PAID CLAIM8. POuCY1NN�0! 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