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Home My WebLink AboutApplication and WC .� - ,. �,,.� — � TOWN OF YARMOUTH BOARD OF �n � a� ° ��d� °D � APPLICAI'IQN F4R LTCENSE/P,, .L > �� , 1+ �' ', �' ¢_ ,�� NOV 2 0 ?f►09 � ; . * Please complete form and attach all necessaryr�o�� ?�um�'ts$y ecember •� H Utr� . Faiaure to do so will result in the return af your application packet ,�_._��_.,. NAME OF ESTABLISHMENT: p r� � �/I TEL. #��'��f��'�� LOCATION ADDRESS: S �, ' -; W �,� MAILING ADDRESS: Sc OWNER NAME: . a ��rn D FE or N � /� -� CORPORATION NAME (IF APPLICABLE�: �.._._.._._.�.-.� MANAGER'S NAME; `� TEL. # MAILING ADDRESS: - ....–._.�.��.�....,_�_��.,�_.�_._��,_,._,_,,,�...__,_.,.__�_._ POOL CERTIFICATTONS: The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated Pool Operator(s) and attach a co�y of the certification to this form. 1. 2. Pool operators must list a xninimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies o�'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. 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, 145 CMR 590.000. Please attach copies of certification ta this application. The Health Department will not use past years'records. You must pravide new copies and maint�in a file at your establishment. 1. 2. PERSON IN CHARGE: _ - —- . . _ __ Each food establishment must have at least one Person In Char�e (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATTONS: All foad service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certificarions to this form. The Health Department will not use past yeRrs' records. You must provide new copies and maintain a file at your place of business. 1. 2, 3..; _ 4. RESTAURANT SEAT"ING: TOTAL# ��_�� ,_, LODGING: UFFICE USE ONLY LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE$ PERMIT# LICENSB REQUTRED FEE PERMIT# 1 B&B $55 �'�� `CABIN $55 _MOTEL $55 �INN $55 �CA2�1I' $55 �SWIMMINGP�OL 580ea. ____LODGE $55 �TRAII.ERPARK $105 WHIRLPOOL $80ea. FOOD SERVICE: LICENS�REQUIItED FEE PERMIT# LIC�NSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 �CONTINENTAI, $35 �I D'O �p �NON-PROFIT $30 >I00 SEATS $160 �COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: _ —RESID.K.ITCHEN �80 LIGENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# �,,,<50 sq.ft. �50 >25,000 sq.ft. $225 ,_VENDITiG-FOOD $25 ,,,,,_<25,000 sq.ft. $80 �FRQZEN DESSBRT $40 �TOBACCO $55 xa�cxaivcE: $is AMOUNT DUE _ $ �0,00 . "'""*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** . . . ... .. .. . . . . . 1 � Sa ADMINISTRATION �nder Chapter 152, Section 25C, Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal o€any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACH�D STATE WURKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFLDAVIT 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 LQDGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinaril�and custornarily associated with matel and hotel use. Transient occupants must have and be able to demonstrate tha.t they mairrttain a principal place afresidence 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 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 have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Departme�t to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit u�the pool azea until the pool has been�inspected and opened. POOL WATER 1`ESTING: The water must be tested for pseudomonas,tatal coliform and standazd plate 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)d�ys af closin�. FOOD SERVTCE CATERING POLICY: Anyone who caters witlun the Town of Yarmouth rnust notify the Yazrnouth Health Departmerrt 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 I�ealth Department. Failure to do so will result in the suspension ar 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. OUTDOUR COOKING: Outdo4�'��p�ng,�r��r��n,or display of any food product by a reta�l or food service establishmern is prohibited. N4TICE:Pernuts run annually from January 1 to Dec�mber 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL REN�VATIONS TO .ANY FOOD ESTABLISHMENT, MOTEL OR pOOi. (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. . . DATE: �� Z� D � SIGNATURE: (��-�,'��,�G��,,z�%� � PRINT NAME&TITLE: I�v T� � /�l�S G��,r�� 09!25/09 I# • f � The Commonwealth of Massachusetts Department of Industrial Accidents �aei�r� 600 Washington Street, 7`h Floor ' Boston,Mass. 021I1 � Worlcers'Compeasation ta4areaee Affidavit:Building/PlambinglEtectricai Contractors �at isfirm:t[ea• Pleaac 1"RIIV1'kQi� name_ �V�i'1 � /�G �C / Gt �"�/K. a__ddress: �Z Z. �c7� I !� ��G':� �1"i�-�- ciri ��SS /�/V C/' state• / /� zip ��6��phone# �� jr'�`��4.5� wo�e Location ffull addressl- [�'I am a homeowner perfomung all work myself. Project Type: ❑New Construction�Remodel ❑ I am a sole proprietor and have no one working in anY caPa�ih'- ❑Building Addition ❑ I am an employer providing workers'compensation for my employees worlcing on this job. �ommae�an.t- .f't�G�1��"�r �N �.3 zaaress: �lw�vt�,-- ciri- o�aee#- ies co. ::- ... .,; ,.,;.. - � ,:`:': ;:;' :,'., . �:.�: " .:: ' �-_ ,. ..;:x3' .:,:�;5 .. ,..,-,:s Z a:�y. ,f'^Y.�e:ue�x ,.. � ..,•:�:. ,v..;_:. .,' .:.. ,e-.x. .,.�. I am a sole propnetor,geaeral coatractor,or�omeowner(circle one)and have lured tbe contractors listed below who have the following workecs'compeosation polices: COmifi9Y Yl9IN:� . .� .. .�. . .. : . . � � . . . . . . . addll88' cttv- n�aat# _ �ace eo.... .:� �- . . .: • � . ... ..... . _ .-. ... ._. ... .. . , . _. .-. _. ,� � ,;�s;.M �r a.:; �D�RY�!I �['!!S: CIIY: : �# - ___ . -- -- - _ -— _ - - ---- - - --_ ----- --- - - OAtClEO. .. .- . . .. .--. .. � - � . �- . . . _ ... :;-. . , ,... . .,,.> ` _ . . .. . � '.. �,, .��' --� s�c .::� x.. -_ �F",:..:-;3. �i`�,.�.:...�. ".�, +�l+, }_,.''�`F�.,,�,�y N � Fai�re r secme coverage n neq�ired�der Seetlur 2SA�f MGL iS2 eu lad b f6e ispsa&Mr af eri�ioal pmaNia�f a Ane�p b;1,3N�l�a�/�� Y�'�1►�ment a�weU as dH pwMks la tie form�f a 5'POr WORK ORDER aad a 8ae�[5166.M a day a�t me. 1 aodnsdud t�at a e�py d fiis statemcat my 6e ferwarded b fhe O�ce otlava�sm ot fhe DIA tor carenge reriQc�tlo�. L do bd+eby ce ' xwder�lYe pa�wa au�pareJNes of iRy dGat tlYt ieforwimlon provided oboae Ls trrte rted corrert S'gnat�"'` G�CG<Y"�L� Date // /7 !,/ � I/� � /��li S er/�ru [1-�. Print name V Phorn# .f'O� 3�Y ��'�L� �ctai ase aoly aa sat wr#e�r�is arPa a ne cespktea by.d(y er fnva�o�cial . e�lY or bwe: ;.P�$ fL�an�� ❑e4ect if�eme�aa reapsme is requir+ed . �°��'� �'s O�te . astact @asen: QHeakk Depar�at t�s�.ma3� �°1°� C"lo�