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Home My WebLink AboutApplication and WCI •� � � V �� Towx oF Y�ou�s Boaxn o ��,� a G C�t�o APPLICATION F4R LTCEN - 1� ' "�; * ". �l JAN ? � . 0 Please complete form and attach all neces d�en s Dec �-- Fai�ure to do so witl result in the retum of your application c �� „�_�.�.�_� NAME OF ESTA�LISHMENT: _ �,�Z�.tI�G��.�1�2� 1L�N TEL. #��Tq'�.ggt 2 LOCATION ADDRESS: q�! MA)�-i �° yfr,zn�a�,�-„� ,�r�- o�6c�., MAILING ADDRESS:____. 4/a OWNER NAME: �t„!v ,�r�t.tr Y -Z,,,i2,��" T�.�ID (FEIN or SSN)L CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:��i�} N�t'�,� TEL. #�,�S�qfr Q��2 MAILING ADDRESS:_ q6/ /�t�N �T S�o: �/�10 i�l �viA ��,2G�G � ,--- POOL CERTTFICATTONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Paol Operator(s) and attach a co�y of the certificarion to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First A.id and Comtnunity Cardiapulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. Yon must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION�vIANAGERS - 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 application. The Health DepRrtment will not use past years'records. You must provide new copies and maintain a file at your establishment. l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HETMLICH CERTIFICATIONS: All foad service establishments with 25 seats or more must have at least one employee traincd in the Hei.mlich 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 aot use past years' records. Yau must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. ' RESTAURA,NT SEATING: TOTAL# � OFF'�CE USE ONLY LODGING: ' � LIC�NSE REQUIRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT# LJCENS�REQUIRED FEE PERMIT# � „�B$cB $55 �CABIN $55 �MOTEL $55 �Q�Q� �;,INN $55 _`_,_CAMP $55 � SWIMMING POQL $80ea. 0-- „_LODGE $55 �TRAII..ERPATtK $105 I WI3IRLPOOL $80ea. �IO—� � FOOD SERVICE: LICENS�R�QUIItED FEE PERMIT# LIC�NSE REQUIRED �'�E PERMIT# LTC�NSE REQUIRED FEE PERMIT# �0-100 SEATS �$5 .lGONTINENTAI, S35 �[ � �T �NON-PROFIT $30 >100 SEATS $160 COMMON VIC. $b0 WHOLESAL£ $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIItED FEE PERMTT# LICENSE REQUIRED FEE P£RMIT# LIC�NSE REQIJIRED FEE PERMIT# I ,�,�<50 sq.R. �50 >25,000 sq.R. $225 �VENDING-FOOD $25 ! ,,,�Q5,000 sq.ft. $80 _,..FRQZEN DESSERT �40 T� �TOBACCO $55 NAME CHANGE: sis AMOUNT DUE = S Z5b�O� **"**�'LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** r �. I .. ,.,.., . . _ .a .�, ; ADMINISTRATION � � � � � � f Under Ch�pter 152, �S�cti'on 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of a�y lic�nse or-per,mi�t to operate a business if a person or company does not have a Certificaxe of Worker's Compensation Insurance. THE ATTACH�D STATE WOItKER'S C4MPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF IlVSURANCE ATTACHED� OR W(3RKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yannouth taxes and liens must be paid prior to renewal or issuance of yaur penmits. PLEASE CHECK ` APPROPRIATELY IF PAID: � YES � NO MOTELS AND OTflER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limita.tions of Motel or Hotel use,Transient oc,cupancy shall 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 demanstrate that they maintain a principal place of residence elsewhere. Transient occupancy sha11 generally refer to cominuous 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 Oca.�pancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as�nended, sha11 generaUy be considered Transierrt. i POOLS � POUL OPENING: All swimnning,wading and whirlpools which have been closed for the season must be inspectal � by the Health Department�prior to openimg. Contact the Health De�artmem to schedule the inspection three(3)days � pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool azea until the pool has been iwspected E and opened. ' j � POOL WATER TESTING: The water must be tested for pseudomonas,tatal 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�round swimming pool must be drained or cavered within seven(7)d�ys af closing, FUOD SERVICE CATERING FOLICY: 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. FROZEN DESSERTS: Frozen desserts must be tested an a monthly basis by a State certified lab. Test results must be sent to the Health: ' Department. Failure to do so will result in the suspension or revocation of your Frazen Dessert Pe�rmit w�til�the , above terms have been met. OUTSIDE CAFES: ' Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior appraval from the Board ofHealth. 4UTDOOR COOI�TG: Outdoor cooking,prepaxation,or display of any food product by a retail or food service establishnnen�t is prohibited. NOTICE:Permits run annuaUy&om January 1 to December 31. IT IS YQUR R.ESPONSIBII,ITY TO RETURN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATTONS TO ANY FOOD ESTABLISHMEENT, MOTEL OR POOI, {i.e., PAINTING, NEW , EQUTPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. DATE: � �/ �'c7 SIGNATURE: - � PRINT NAME&TITLE: 09l25/09 : � � The Commonwealth of Massachusetts Department of Industrial Accidents N�ifCi N�1I�s 60t1 Washingtnn Street, 7`�'Floor Boston,Mass. 02111 + Woricers'Compeasation i�sors�ace Aflidavih Bnitdieg/Ptumbiag/Etectrical Coatraetors A�Hddrt isfac�tati�ss.s Please�RI1�FP le�biv ° n�: C�H��} ff U Y`v!� �2�=�r.v�?3� ,+�1 i�k ;N� �s: 9'Co l A/t�i,�! .s 7� - ,,R - �Q ciri� - y�R�I O(J t� state• M � zin•Q.� &�LF phone# r 5a�,�g=��'�'-g. � wotk site location(fuli�dressr ❑ I am a homeowner perfomning all work myself. Project Type: ❑New Const�uction�Remodel ❑ I am a sole proprietor and have no�e working in any capacity. Q Building Addition [� I am an�ployer pmviding work.ers'compensati�for my employees worlcing on this job. wmoaaveame: !-Ef3R►�dl2h t)Af ' /Z i ��62� fNSU�2A�l1Gt G' �M P►�i�1� address• : citv: o4a�ae M; tss ca V G1' C O _pCC �, ....�.. .� ,. . ;; . .._..,_ >: .. ,=.: ..�_F�. .<, > ��:� ,<.��, �. „;�x .-�;.;,��.��*�.�.-,,,:� � ❑ I am a sok proprietor,geaeral coatnctor,or 6omeewaer(circle one)and have tured the conti�ctors listed below who have the following workers'compensation polices: �v�: add�a- dt9: pkAd!�• _ 1�3U�<O!CO.� � . . . . � . . . . ' . . . . .. . , . . �n�..rx:�:.�s� ... .. . . , _ , x _.. v�:: �...�;'�t�s� < a�d��ss• �9: .. ��. ep. ,. _ _ __ _: � __ _ _ Fa�rs r san+e aa � �:: <_. -� . _�A'� ,�'�.�"* �,�..n��5'�..; �.. �;:��.3��.��:�x�-' crwec'a�e *e9wi�'ed udQ Satlaa 2SA�f MGL 1S2 a�kad t�tYe �f'ai�ial Me Yars'le�r9o�sAt as we�as dH penitlm�tie tert�[a STOT WORK ORD�dS1A0.N��E'a fe�p b t1,3M.N atdlsr «py.cu�.�.�.�ee t.rw�.�r Omoe lt�atl�tlw of 1k D1A fira�aa�e ve�ntlK. �7�°�e. 1 asdasdtd 1�t a L�o l�e�eby cernfy xnde e yains ' nfPeqirn�'dYat dit iwfonaaHon proelded aboae Lr btire irwd� �� Date � ' `�� '�o . Prinrt name .�oT' /� 7-�U T'� !�- Phone# .�v?s 3 q� ` �� I `Z_ �cial ase aaly do aat w�ite f�thh at+ea te�e a�ple4ed by.ellY er 1rwa�s�e�l . eity or bwc ;_perdfllieaie i f�L�tet..�t ❑ehedc if f�1e napome is reqnired _ �� QSdec�*s O�a . � r10�t�r � �� '