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Home My WebLink AboutApplication and WC _ � �� .l'7 _ ws.. ''_ i � ► TOWN OF YARM�UTH BOARD OF HEALTH ��—��'N � � APPLICATION FOR LICENSE/PE 2 : - � R�`-MAR O g ZO1Z ' t-. 4,:» �� * Please complete form and attach all necessary do e � �� x � e S , Failure to do so will result in the return of your application pac v�" 6 ' ��PT. , ESTABLI5HMENT NAME: '� °J �� ID• : LOCATION ADDRESS: � TEL.#: � �� MAILIATG ADDRESS: � ' OWNER NAME: CORPORATION NAME APPL • LE): ' MANAGER'S NAME: 1 �l C��. 6 TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy af th�certification to this form. f; . _ _ __ __ ,_ _ 1. � �� 2. Pool operators must list a minimum 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 of employee certifications to this form. The Health Department will not use past years' records. You must provide n�w copies and maintain a file at your place of business. l. 1 f ' 2. , 3. 4. FOOD PROTECTION MANAGERS - 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 to this application. The Health Department will not use past years'records. You must rovide new copies and maintain a file at your establishment. 1. � 2. ; . i P�R�4�i IN�H�.GF:_ _ , _------------- - — ---____ __ _- _ _ ' . _�_ _ Each foo establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food 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-choking procedures below and attach copies of 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. , 1. � 2. 3. 4. ' RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICEIVSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _lltiiv $�5 _CAMP $55 1 SWIMMWG POOL $80ea. Z^'tQ s _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. ' FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFTf $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<50 sq.ft.. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ E3Q•O� � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** '. ADMINISTRATION � Under Cha ter 152,Section 25C,Subsection 6,the Town of Yarmouth is now re uired to hold issuance or renewal I P q 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 �FFT�3AVIT MUST BE COMPLETED AND SIGNED, OI2 CERT. OF INSURANCE ATTA��D . OR WORKER'S COMP. 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 ' 14�I��i.S �l'�f�'��R L€3�l��1��°�:�TA�3L�S�4�V�i'�` 1 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 shall 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 OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected by t�ie Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days ; prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected ' and opened. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count � by a State certif'ied lab, and submitted to the Health Department three (3) days prior to opening, and quarterly i thereafter. ' --- - POOL CLOSING: Every outd�or 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 inspected 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 T'own's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. r FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results i 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. k ; OUTSIDE CAFES: r L lUG J 1. . 1. t.i • • .� .�,. °i � ��F' r h��P^*'+��a*��'��al frnm thP Rnar�l nf H � l � �'7'v'2�3'�{1F�£�t''� S:$rE....,��A��.----•-r--__ --rr� ea�l._ - -- OUTDOOR COOKING: Outdoor caoking,preparation,or display of any food product by a retail or food service establishment is prohibited. ! ; ; � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2011. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POO�, (i.e., PAINTING, NEW EQUIPMENT,E I C.),MUST BE REPORTED TO AND APPROVED BY THE B4ARD OF HEALTH PRIOR TO CO NC MENT. RENOVATIONS MAY REQUIRE A S E P N. , " � �DATE: � I.S� �� SIGNATURE: �" � PRINT NAME&TITLE: �.� ,�% ' rzP�. �o�2sn i l �� , � � ( � �`"� The Commonwealth of Massachusetts Deparhnent of IndWstrial Accidents > �a��i • � . _ � _ � :. , . . 60D WashiRg#o�Street, 7`�'F[opr �. , � . . i ' � Boston,Mass. :Qllll : - .: ?,:�: f � . � ( Worlcers'Com asation I�aiante AfiidaYih y.�� —y q ' F'J.... . 1� _ .�..��riA.i.�jx�. �.:�� _a s'�rt � .. ,.��E�lf , '. I f name: , ; , : .. . 1 _ - ... . . ,; _: i addnss_----- ---------- , , I city state• zio• nh�e# , work site lceation(full addiessl• ; ❑ I am a homeowner performing all wark myself. , ❑ I am a sole proprietor and have no one working in any canacity. { ❑ I am an employer providing workecs'compensation f�my employees wodcing on t6is job. � _ _ . � _ _ , _ : , 9 li y — ...�-. � i-G �m ��.. � �-*�::'�} �:.�.�.i " . .� . �.'y:£5�.�1'°�{ii$YYc 3.::.t. .r X✓ ��d- �..v.n......�'E� �. . . . . .. ` 1 �� CItY: Q�IOR!M' IOf��tlCO. . . .. . . , . � .. . . . � �* .... � . .. , .� . �.,.. . � - � ❑ I am a sole,proprietor,ge�erai eo�tractor,or.6omeowser(cir%one)and have hired the contr,�ctors listed below who have '. Lhe fo(lowing wockers'compensationpolices: , ! . . , _,_ . . . ' .� �., e . ;.. ,,. ,.:r ,T � , -: . : r, . . ..,.s. , . .. . . . . . . _�_. , _:-. . '. .. ' -.., .. -�.� .. .. . . �.,�. .. � ... .. .. . . � _.., ... .. `�.. 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