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Home My WebLink AboutApplication and WC ~� ; TOWN OF YARMUUTH BOARD OF HEALTH B W��1224 MA�o2- � � APPLIGATION F4R LICENSE/PERIVIIT-2010 �.,��7� . * Please complete form and attach all necessary:documents�t��Dece» er X 2049. Failure to do so will result in the return af your applicat on pac et. NAME OF ESTABLISHMENT: TEL. #�_;;��C� LOCATION ADDRESS: MAILING AUDRESS: sa.+� OWNER NAME:.�,. ,�,'�-f-,�„r-;c�. 5�� .. T�ID IFEIN or SSN�,:_, CORPORATION NAME IF APPLICABLE): MANAGER'S NAME: L, TEL. #�,�-.3�2-7��0 MAILING ADDRESS:: �-ec.w�, •c. 1��11��AI��A�I�I�O��III�M��I� POOL CERTIFICATTONS: The pool supervisor must be certified as a Pool Qperator,as reqruired by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this fortn. 1. 2. Pool operators must list a minimwm o£two employees currently certified in basic water safety,standard First A.id and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wi11 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, 105 CMR 590.000. Please attach copies of certificatian ta tlus application. The Health DepRrtment 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 estabiislunent must have at least one �ersoan In C;harge (PIC)on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: 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 times. Please list your employees trained in anti-chokuig procedures below and attach copies of emplayee certifications to this form. The Health Department will aot use past years' records. You mnst provide-new copies and maintain a file �t your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL# � ._. OFF�CE USE ONLY LODGING: LIC�NSE REQUIRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $55 �(�OO� _CAB1N $55 _„M4TEL $55 lNN $55 ,_,_CA.MP $55 �SWIMI�ZTNG POOL 58qea. _LODGE $55 ,_,_TRAILERPARK $1p5 WI3IRLPOOI. $80ea. FOOD SERVICE: LICENS�REQUIRED FEE PEt2MIT# LIC£NSE REQUIRED �$E PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 � ��ONTINENTAL $35 �?� �NpN-PROFIT $30 >l00 SEATS $160 �COMMON VIC. $60 WHOLESALE $80 RETAQ,SERVICE: �RESID.K,ITCHEN $80 � LICENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT# LTC�NSE REQUIRED FEE PERMIT# _„<50 sq.fi. �50 �>25,000 sq.R. �225 �VENDING-FOOD $25 „_<25,000 sq.ft. $80 .�FROZEN DESSERT $40 TOBACCO $55 NAME CHANGE: $is AMOUNT DUE _ $ �Q,,p� ; """"*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"*� .-► , r ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmauth is now required to hald issuance or renewal of any license or permit to operate a business if a person or compa.ny does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taazes and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK APPROPRIATELY IF PAID: YES^� NO MOTELS AND OTHER LQI�GTNG 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, ord�naril�and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they mairttain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, atnd 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�mended, shall generally be considered Transient. POOLS POUL 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 Departmerrt to schedule the inspection three(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to sit in 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 CATERING POLICY: Anyone who caters witlain the Town of Yarmouth must notify the Yarmouth Health Departme�nt by Sling the required Temporary Foad Service Application form 72 hours prior to the catered event. These£orms 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 Health Department. Failure to do so will result in the suspension ar revocation of your Frazen Dessert Permit untit 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 COOKING: Outdoor caoking,�reparation,or display of any food product by a retail or food service establishme7rt is prohibited. _- NOTICE:Pernuts run annually from January 1 to Dec�mber 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN THE COMPLETED RENEWAL APPL�CATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL, RENOVATIONS TO ANY F4(�D ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �_� SIGNATURE: PRINT NAME&TITLE: G�22�, c� D h ��ca•,�.cj►,e r {--�u.5�.H� 09l25l09 s � . � The Commonwealth o Massachusetts f Department of Industrial Accidents �fri�ilirrrsf�sis 600 Washington Street, �b Floor ' Boston,Mass. 02111 � Workers'Compeasation iasaraaee Affidavit:Bailding/Pt�mbi�g/Electrical Contractors A�i�e�t fwfermi�• Pleaae PRQVT k�M�r �: .�t. 1/,-,._ r�s: �c�,.�.,�t add[�Ss: �l'--., D /"L QG i..s ��-� ciri�Y�i'JL-�'��^T. state- �H zin-0�� 7�phone# (�L�—�b 2 7�Q tJ wotk site location(full addressl_ ❑ I am a homeowner performing all work myself. Project Type: ❑New Construc,Kion QRemodel �'I am a sole proprietor and have no one working in any capacity. ❑$uilding Addition ❑ I am an employer providing workers'compensation for my anployees wo�lcing on this job. oomPasv nme: _ . _ _ : _ _ _.__ - . ad�'ess: � citv- oJ�aae!!- co. , ,., ,. ,; ,___ nr� ..,: ,. ...;,:� rx� .. . �• �.�*.a:�-��x:,,�..:;<: . : ,-, ,_..: K , ;: . . ;. ...: .N:..; ;� � I am a sole proprie.�or,geeeral contractor,or homeowner(cirde o�and h�ve}ured tbe contractors listsd below who have the following workers'compensation polices: ':4 cemw�v�: � .,��. address� ctiv n�ute#. �aa�aaee co. , , # - �..,a' . . : . _, �...?`;4-�,� �i Yml: !�' CI_ls7 ��. _ _ _ - --.w. .. — : , ._, � _ __ __ ..... ... ... ... .:.. ... �. ...'. ..... .:.'� .�.':: :. �.L �::� �2, .-%:t 92..x..�i".4 5�'�'h9�. 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