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Home My WebLink AboutApplication and WC rn �lJ�OF YARMOUTH BOARD OF HEALTH �: � � �� < � � APPLICATION FOR LICENSEIPE�i►N�-��.0` �� ;� . �� - ;. *Please complete form and attach all necessazy d�c�um�ts by Decemb . l S��0�S ZQ�0 Faiture to do so will result in the return of your application pac et. ��g�� NAME OF ESTABLISHMENT: Qc .��` �%1`! TEL. # �d F`2'7 ' g3 LOCATION ADDRESS: �' �r v r MAILING ADDRESS: d Si�2 . Q• OdG rl . OWNER NAME: 4�'1�' so� F • �/'�� ' CORPORATION NAME (IF PPLICABLE): MANAGER'S N.AME: �`!�r �z�� TEL. # O�407 j MAILING ADDRESS: �� c. GC1• Q�-�. a. ' � 3 POOL CERTIFICATIONS: ' The poot snpervisor must be certified as a Pool Operator,as required by State law.' Please list tb.e designated Pool Operator(s)and attach a copy of the certificarion to this form. ' 1. 2, Pool operators must list a minimwn of two employees currently certified in basic water sa�'ety,standard First Aid and Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below an�attach copies of employee certificarions to this form. The Healt6 bepartment vwill'not use past years' records. You must provide new copies and maintain a file at yoar place of business. 1. 2. 3. 4, —r—,—•----- FOOD PROTECTION�iANAGERS-CERTIFICATIONS: All food service establishments are required to have at least ane full-time employee vu�ho is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Seivice Establishments, 105 CMR 59U.000. Please attach copies of certificatio�to this applicadon. The Health Department will not use past years'records. Yon must provide new copies and maintain a file at your estab6shment. 1. 2, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hcaurs of operation. 1. 2. HEIMLICH CERTIFICATI(JNS: ' All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all tiames. Please list your enployees trained in anti-chokuig procedures below and attach cogies of employee certificarions to this form. The Health Department will aot�use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3• 4. RESTAURANT SEATING: TOTAL# . LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENS�R;EQUIRED FEE PERMIT# _B&B $55 _CABIN $55 ,_MOTEL''; $55 $55 �CAMP $55 �SWIMM►NG POOI. $80ea. LODGE $55 �O�I _v TTRAII,ERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIItED }"EE pERMIT# LI ENSE REQUIRED FF,E PERMIT# LICENSE R�QUIItED FEE PERMIT# _0-100 SEATS $85 �GONTINENTAL S35 �I b�fq� �NON-PROFIT $30 >1d0 SEATS $160 _COMMON VIC. $60 �WHQLESAI.� $80 RETAII.SERVICE: —RESID.KITCHEN 580 LICENSE REQUIItED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SO sq.R $50 >25,000 sq.R. $225 _VENDING-FOOD $25 �Q5,000 sq.R. S80 _F'ROZEN DESSERT $40 _„_TOBACGO $55 NAME CHANGE: $15 AMOUNT DUE _ $ /D�� """•"�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' o � ' ADMINiSTRATION . � # Under C�ter��52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renevval of any license or permit tb operate a business if a person or company does not have a Certific,�tc of Worker's Compensation Insurance. ' THE ATTACHED STATE WORKER'S COMPENSATIOI�T INSiTRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR - CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes�and�liens must be paid prior to ren�wai or issuance of your peimits. PLEASE CI�CK APPROPRIATELY IF PA1D: - YES N4 1V.kOTELS AND OTHER IADGING ESTABLISHMENTS TRANSIENT OCCIIPAI�ICY: For purposes of the limitations of Motel or Hotel use,Trans�em occupancy shall be limited to the temporary azid short term occupancy,ordinarily and customar�y associated with motel and hoted use. Transierrt occupazrts must have and be able to demonstrate that they maintain a principal place of rersideace e�sewhere. Transient oc�upancy shall' generally refer to comuiuous occupancy of not more thaa thirty (30) days, and an aggregate of not more tham ninety(90)days within any six(6)month period. Use of a guest urrit aa a t�esidence or dwelling unit shall not be �onsiderecl transient. Occupancy that is subject to the collection of Raom Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall geaerally be consider�d Transimrt. POOLS POOL OPENING:All swimnning,wading and whirlpools which have been closed for�seaaon must be' by the Health Departmetrt�nor to openimg. Contact the Health Deparnnem to schedule the inspection thrbe(� pnor to opening.PLEAS�NOTE:People are NOT allowed to sit in the pool area until the pool has boen u� and opened. POOL WATER TESTIl�tG: The water must be tested for pseudomonas,total coliform and standard plate cowrt by a State certified lab, and submitted to the Health Departmecrt three (3) days prior to opening, a�d quarterly thereafter. POOL CLOS�NG:Ever�outdoor in ground swimming pool must be drained or covered within se�ven(7)days of closing. FOOD SERVICE CATERING POLICY: Airyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departcnem by tt�e requu� Temporary Food Service Application form 72 hours prior to the catered event. These fornis can bes��at the Health Department. k'ROZEN DESSERTS: '' Frozen desserts must be t�sted on 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 Frozen Dessert Perimt uat�the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHeahh. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishme�t is prolu'bited. NOTICE:Permits run ann�ually from January 1 to December 31. IT IS YOUR RESPONSIBILII'Y TO RET{JRN THE COMPLETED RENEWAL APPLICATION(5)AND REQLTIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATTONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POO�. (i.e., PAINTiNG, NEW EQUIPMENT,ETC.),MIJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT.' RENOVATIONS MAY REQUIRE A STTE . DATE: /'-? ' 9��' SIGNATURE: PRINT NAME&TITLE: V o � � r Q� o9ns�o9 M ' �\ The Conemonwealth of Massachusetts Department of Indusd77al Accidents NJ��w�� 60l1 Washington Streeti 7`�'Floor Boston,Ma�s. 02I11 Woricers'Compeasation iasorance Aftidxvih Bsiiding/Plambieg/EleMrical Coatraetors �isfi�� Ple�e Y'lt�I+tl'ie�is , �: /��'/'ICY �' l�a`l�7sm�i �s: i'�J /��'�'�/ i�!v�� C11Y� Ki!'� �7�L� ��t' . . ShdYC' i'//!�t• � Z1D'-Q��[M' �IIWIIC# 4? DO 7l O �O I�� WO[�CStCC LOCHtI0I1(fllll 2ddiCSS�:_ �- . . . . (j�i am a homeowner perfomnng all work myself. Project 7ype: ❑New C�on QRemodel ❑ I am a sole proprietor and have no�e working in any capacity. Q Building Addition ❑ I am an employer providing w�ke�'compeasati�for my eanpby�s wodcing ai this job. wmwa��ame- address: citv: oioae N- ce. :a , :..�:;.. , " . . � . .-. 1 .,v,"s;.�, • �:': a ° . �.�,;. . . ��. s.�-Ti. .c ,>...� �s_.-� .K...•. .. . .. ._' : ��, .,s....�.. .... _.. ,:�.. � .�-a' e_fa..+`k: atF rd.a.w".F�ts".. :3.'N I am a sole proprietor,geaeral coatncter,or homeowwer(drele o�)and have hired tbe�tois listed below who have the foliowing wocicers,compensation polices; ��iamt: �: ' dtr. 4 ��• _ . c.. ' � ;:;; <�_;�:�:,. :.. ::. . :: . � a �. �.3 �. -.._: .->, .,, . ...-. . .: .� �. - - . ��. . .. . �. ..,-.. • , . .;., . . _. .:;<. ..;�,.: .. . . .. -. <.... ,:. . .. .. . ». . _ . .- .s��rX Y;�_'��'x ,.. �i!�E' �[d�' �Y: : . . .' . , . . . . p�0�!�' . , .. . �'� � . � . . 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