The URL can be used to link to this page

Home My WebLink AboutApplication and WC ..�. � �,..a.__.s � . ,. ��._.-�.�. --�� r� TOWN OF YARMOUTH BO RD OF H�„A �� P,.��, _ = APPLICATION FOR LICENS /PI+�II�I'F-�'!�M �� G` � � ' �� .;�� c� � ;=� * Please complete form and attach all neces ' ��i�i � er ±LL` 1 :`; � Failure to do so will result in the return o your application pac et. ESTABLISHMENT NAME:� '��/OvV� \�1� � TAX ID: LOCATION ADDRESS: r� Qa. EL.#: �-�� MAILING ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certiCed as a Pool Operator, as required by State lativ. Please list the designated Poo�perator(s) an attach a co�y of the certification to this form. �: 1. � �-�L 1�D� 2. Pool operators must list a minimum oftwo employees cunently certified in basic water safety,standard Fust Aid a�id Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certificatians to this foi-m. The Health Department will not use past years' records. You must provide ne��r copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establislunents are requued to have at least one full-time einployee �vho is certified as a Food Protection Manager, as defined ui the State Sasutary Code for Food Seivice Establishments, 105 CMR 590.000. Please attacli copies of certification to this application. The Health Department will not use past years' records. You must provide ne�v copies and maintain a file at your establishment. .1 2 PERSON IN CHARGE: Eacii�ooil establislu�ient must liave at Ieast oiie Person Iii Charge (PIC) on site duruig liours of o�eration. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained ui the Heunlich Maneuver on the premises at all times. Please list your employees trauled in anti-chokuig procedures below aud attach copies of employee certificatious to this foini. The Health Department will not use past years' records. You must provide nefv copies and maintain a file at vour place of business. 1. 2. 3- 4. RESTAURANT SEATING: TOTAL # �FFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER'vIIT# LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERYIIT# _B&B S�5 _CABIN S�5 �20TEL S55 _INN S55 —_---- —CA;�IP Cji �S��`L'1�iVIPVGP�.^�Oi. S802n. ��y _LODGE S» `I�RAII,ER PARK S 10� ��-IIRLpOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT z LICENSE REQUIRED FEE PER�IIT= LICENSE REQUIRED FEE PER�III'� _0-100 SEATS S85 _CONTINENTAL S3� NON-PROFIT S30 _>100 SEATS S160 _CO'_�L'�ION VIC. S60 ��'HOLESALE S80 RETAIL SER�'ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�IIT� LICENSE REQUIRED FEE PER��IIT� LICENSE REQL?IRED F�E PER�4IT� <50 sq.tt. S50 _>25,000 sn.it. S225 �'ENDING-FOOD S25 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S» �.�viE c��cE: sl; AMOUNT DUE _ $ �0 . p(� *****PLEASE TL'R\OS".F.12 A�D CO�IPLEI'E OrHER S1DE OF FOR�1***** \ i ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth 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 Gompensation Insurance. THE ATTACHED STATE WOI2KER'S COMPENSATION INSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGI�TED, OI� I ; CERT. OF INSIIRANCE ATTA.t�HED ' 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 1�I0"TEi.a A�Vl) t�7'HER ti.(3I��GI�v ii E�Tf��i.ISii�"i�:N TS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 i 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. i . 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 Department to schedule the inspection three(3)days pnor to opemng. 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. POOIa 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 ta 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 atthe 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. I OUTSIDE CAFES: i Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ' _ _ __ _ _ _ _ _ _ _ i OUTDOOR COOHING: : Outdoor cooking,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 RESPONSIBILI'TI'TO RETiJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. I ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW � EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEM T. RENOVATIONS MAY REQUIRE IT P N. DATE: .� 1 SIGNATURE: � PRINT NAME&TITLE: ` � -` � , 10�06'10 � � � r ' s t�i.�s�r?�v�► � Y�mou�� K�tac�x 1�r, ` � !(�f� �ourE Z8 - The Comnronwealth of Massachusetts � � DepartmeRt of I�dastrial Accidents �, �� y�M��Mk NAfriNi� � _ Q266�( f 600 Washington Street, 7'�Floor ° � Boston,Mass. 02111 � F�� Q�j(�j� �' Workers'Compensatioa Imerante ARidavit: Buiiding/Ptambie�JEleM�ica1 Contractors � j t �-rt� - wt .,�e a�_, i I18fOC: ` , '� �1� ¢ � � � �[L.A a__ddress: _ ��— ��--��-�`��------ ----- 1 s te_ zi r � �� b ��^ S � work site(ocation(fiill address): i ❑ I am a homeowner perfornung all work myself. Project Type: ❑New Constniction�Remodel ; ❑ I am a sole proprietor and have no one working in any capacity. ❑Building pddition ' ❑ I am an emptoyer providing workecs'corn nsation for m em lo e = �� v��J�� Pe Y P Y es working on th�s�ob. , ---. ._ _ _ - - _ ; -- - __ _.____�_---- —_ _--_ _ .- _-_ _ _ _---- z�toarv�e: address: i citv- nlioae N f Insm�avoe co. �# � ❑ [am a sole proprietor,geaerai co■tractor,or 6omeo�vner(circJ�on�)and have hired the contractors listed below who have ' the following workers'compensation polices: a►mwav aame: address• f citv oiose N � iwsma�ee ca � i �muuv oame. addras: ' cjiv: oro�e N ___---___-- .--- _ __k��mraa�r% __ _ _ __ -___-- - ---_____— _— ___. __ � - —__----- — _ # Aldtli ai��/t�ut�tra�r Failve 6�xtue aKrade as reqdred��der Seelfo�2SA�t MGL 152 cu Ind b tYe isphiW��f a1�1u1 peaaNb�[a A�e�b f1,3i�M aid/K �Yb�'��r�,.�.��wrn,�d,��n�ro c�r.r.er.sTor wonic onnEx.sa.e■�ar sia.a a day ataidt�e. 1 oaden�d t�aat a c�py st tib�tahmem�r 6e fo 6s tAe dAice.i�?Im�e�tl�et t6e D1A far e�vense veriAeatla. /do 6errby cerBfy wnder Nie es pen hi '6jperfrry tlYtt NYe fwfo►w�rtdon prov�ded oboae Ls trrre d co Signatute F�� Date � � �� Print name Phone!� v atBelai nx oaty do aot wrke d this arn to be rnvp{eted by dty or 6�,wn n@ieia� J city or towo: P��N�� OBaidioa Depar�ent ❑eLecl[if immediale me is ��s=Beard �Ps r'�9�red OsdKc�.'a cka« ��c .. OHa�n�.�.t �° • phoee 8; �� c�a s�.mm�