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Home My WebLink AboutApplication and WC • � r ,.� . �� ' � �� `' � �'�'�t �, � TOWN OF YARMOUTH BOARD OF HE,�,� , , = APPLICATION FOR LICENSE/PT+�F��'�,2� �_: -, e_.e `"� ; a �, ,'� ' �� ' s' ; ' , �.� L�. �� * Please complete form and attach all necessary documen s y De m �D T Failure to do so will result in the return of your application ESTABLISHMENT NAME: �N C Ll �f��Ca� �a( � TAX ID- LOCATION ADDRESS: /Z Z So v Ti� .sfl c��$� 1�riv L TEL.#: j�r�Y- j,�-—�Z LS' MAILING ADDRESS: ��'� - OWNER NAME: (�i'�RS) (�v�7'�f j• /��J 5'G iA R c�T7"� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL #• ._.._...__ MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator�s) and_attach a co�y of the cet-tification to this foi�rn. 1• 2. Pool operators must list a minimum of two employees cun ently certified in basic water safety,standard Fu•st Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees belo�v and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide ne�v copies and maintain a Cle at y�our place of business. 1. � 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requued to have at least one full-time enzployee who is certified as a Food Protection Manager, as defined 'ui the State Sanitary Code for Food Service Establislunents, 145 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. L 2. PERSON IN CHARGE: Each food establisiuilent must have at Ieast one Person In Charge (PIC) on site during hours of operation. 1• 2. HEIMLICH CERTIFICATIONS: All food seivice establishments �vith 25 seats or more must have at least one employee ri•ained in the Heunlicll Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this foi�ni. The Health Department will not use past years' records. You must provide new copies and maintain a file at`�our place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERI�IIT?* LICENSE REQUIRED FEE PER��IT# LICENSE REQUIRED FEE PERiVIIT� �B&B Ss5 �!!DO_'� _CABIN S55 _MOTEL S55 _�N S55 _ _CAMP $ij _C��'I;1��I_ij��CipnQT C$Clea. _LODGE S55 �TRAII,ERPARK S105 ��'�'HIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT z LICENSE REQUIRED FEE PER��IT� LICENSE REQUIRED FEE PERiviIT� _0-100 SEATS S85 �CONTINENrAL S3� #'II—O l3 _NON-PROFIT S30 _>100 SEATS S160 _COMMON VIC. S60 _��IOLESALE S80 RETAIL SER�'ICE: —RESID.KITCHEN S80 LICENSE REQL�IRED FEE PERYIIT# LICENSE REQUIRED FEE PER�1Ir.~ LICENSE REQUIRED FEE PER1r1IT~ _<50$q.t}. S50 _>25,000 sq.ft. S225 _VENDING-FOOD S2� _Q5,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO S» \AVIE CHA\GE: S1� AMOUNT DUE _ $ 90 . 00 *****PLEASE I'L�Rti O�'ER ArD COv1PLETE OTHER SIDE OF FOR�i *«,.*,� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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 COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, �R CERT. OF INSURANCE ATTACHED Odt WORKER'S COMI'. 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 iYIG►7f'E�,�E�fD fS'1'li�I2 L1�31'➢Gi�V��.�i r11i�Y�H1VVI�N 1 S TRANSIENT OCCUPANCY: For purposes of the 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 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 Department prior to opening. Contact the Health De�artment to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to srt 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 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.varmouth.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 Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohi6ited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTI'Y TO RETURN 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 EQLTIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �� /� SIGNATURE: j.2v�� c;�-�J°�. PRINT NAME&TITLE:�� /�, /�� ' ��'��-� — o �-�� ' 10'06 10 i , � y _ � The Commonwealth ofMassachusetts Departnrent of Industria!Accidents ��lbw� 600 Washington Street, f"'Floor Boston,Mas� 02111 Workers'Compensation Insorance,Aflidavit: Bailding/Plambio�/Electrical Contractors �t isfsra�atin• Pksse PRIN'!'k¢!bh namc: �� l.�T� � /%/�/ Gl g �2 L' /�7C aadress: �Z Z_ SG r/,Z/�--.S-fT u1��__pl�/V_�--------------- ciri ��S'S ��VF_R state• /��J zio u2GC y o,,�# ,�—a� ,�Ss� �Ze,jJ work site iceation fiil1 address_ ❑ I am a homeowner perf'orming all work myself. Project Type: �New Constivc,�tion ORemodel I am a sole proprietor and have no one working Yn any capacity, �gui��ng q��ion ❑ I am an employer providing workers'cornpensation for my employe�working on t6is job. _ - --_ ----,�_____:__ _ _ — _ . , _ _ _ . e _ -_::E .._ :-�: _ �m same: , ad�ee�s- cltv: o6oae N insmisce ca # ❑ I am a sole proprietor,general coatractor,or 6omeo�vner(circl�one)and have hirad the conhactocs listed below who have the following workers'compensation polices: co addre�• citv: DIIOS!# �ASIQfOt!CQ # ��fdf: ��' D�O�!M i� _ eo, __ _ Ml�e!�d�l ie�et It�een�� Faihre 0�xeare ovvcrase as reyefred�sder Sectlo�2SA e[MGL 132 eu kad b tYe��f vto�dal ose ydn'ImpMsoameat as we8 as dvi peaaltks ie tee[er�o[a 3TOT WORK ORDER asd�eee d S1A6.0s�a da�•t a sne�p t�f1,3M-Or aaN�r cepy e[t�(s ffaoemeot may be for+►arded te t6e O�Ice o[lave�tl�m ot the DIA for c�verase veriAeatla. Y�m�me. 1 ondenhud thaf a /do ker+�by certify wnder Mie palws and penelHes of perjury tA�et rlUe ixfonMroyon provlded obo►�e Is d�e raed rnrrert Signatu�e��(� /r ��G�..l.�-�La✓_i�� Date _ ///�//D Printname � v � ��f�'� ��r'r,,� Phone#_f7r � -�S'Y '�`ZL1� uf�cW ux oNy do not wrke ia this area to 6e rnmplefed by dty or�wn o@kiai .. _ dry or tawn- pennlUNceme q �Batidina Deparimeat ❑eheck if iremediah rc�eex b reqoired �Liceesiet Boar+d OSekctmea's ck8ae t��°' p6oee it; �xh��rtiec°t � Q