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Home My WebLink AboutApplication and WC ' TOWN OF YARMOUI'$BOARD OF [�L C�C��d��° APPLICAITON FOR LICENS - ,� �� (e°� MAY 2 7�2010 i *Please complete form and attach all neces y D utr� +• � Failure to do so will result in the retu f your applicat� no pac �i. i � � "s ; NAME OF ESTABLISHMENT: '� - • w�'� S�iTEL. # ��C)-t��1 LOCATION ADDRESS: '� e, � -� MAILING ADDRESS: �. r i OWNER NAME: p CORPORATION NAME (IF APPL LE): MANAGER'S NAME: TEL. # -'1 -1 rl� MAILING ADDRESS: �'� 3, � POOL CERTIFICATIONS: �oN S-rwtz2� {'�,� MCr�. �s�73�-75�y The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificarion to this form. l. 2, Pool operators must list a minimum of two emp loyees currently certified in basic water sa�'ety,standazd First Aid and Commwuty Cardiopulmonary Resuscitation(CPR). Please list these employees below an�i attach copies of employee certificarions 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. q., ..-._.�_.,�.._, �..._.,.�_ FOOD PROTECTION�iANAGERS - CERTIFICATIONS: All food seivice 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 Establishrnents, 105 CMR 590.000. Please attach copies of certification to this application. Thc Iiealth Department will not use past years'records. You must provide new copies and maintain a file at your estabGshment. ' 1. 2, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food scrvice establishments witb 2S seats or more must have at least one employe� traincd in the Heimlich Maneuver on the premises at all times. Please list your enployees trained in anti-chokuig procedures below and attach copies of employee certificarions to this form. The Health Department will aot�use past years' records. Yoa mu�t provide new copies and maintain a file at your place of business. ' 1. �. 3. 4 RESTAURANT SEATING: TOTAL# LODGING: OFFICE USE ONLY ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE R;EQUIRED FEE PERMiT# _.B&B $55 _CABIN $55 ^MOTEI,'' $55 �11VN $SS �CAMP $55 I SWIMMING POOI. �80ea. ��C3� ,LODGE S55 TTRAILERPA.RK $105 �WHIRLPOOL $80ea. FOOD SERVICE: ' LICENSE REQt.TIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE R�QUIRED FEE PERMIT# _0-100 SEATS $85 _CONTiNENTAi, $35 �NON-PROFIT $30 >100 SEATS 5160 TCOMMON VIC. $60 �WHOLESAI,� $80 RETAQ,SERVICE: —RESID.KITCHEN S80 LICENSE R$QLJIRED FEE PERIv1IT# LICENSE REQUIltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SO sq.R S50 _>25,000 sq.ft. �225 ____VENDITiG-FOOD $25 ---QS��•� �80 _.FROZEN DESSERT $40 TTOBAC�O $55 NAME CHANGE: sis AMOUNT DUE _ $ �b,�� ""*"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• r . ; ADMINISTRATION , :� Ur�der Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or rentvval of any �ice�i� ot�perinit tb operaxe a business if a person or company does not have a Certific�te of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiJRANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED_�/ Town of Yarmouth t�es a�nd liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PA1D: YES NO MOTELS AND OTHER LUDGING ESTABLISBMENTS T'RANSIENT OCCUPAP�TCY: For purposes of the limitations of Motel or Hotel use,Transie�rt occupancy s�sall be limited to the temporary a�d short term occupancy,ordinarily and customarily associated with motel and hottl use. Transie�t accupams must Ylave and be�.ble to demonstrate that they mairnain a principal plave ofresideace dsew�e. Transient occupancy sha11" generally refer to cominuous occupancy of not more than thirty (30) clays, aud an aggregate of not more thaii ninety(90) days within any sus(6)month period. Use of a guest urrit as a residence or dwelling unit sha11 not be Considered transient. Occupancy that is subject to the collection of Room Occupaacy Excise, as d�fined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Traasieat. POOLS POOL OPENING:All sv�imming,wading and whirlpools which have been closed for the season must be' by the Health Departme�nt�prior to opening. Co�ntact the Health Departmem to schedule the inspe�tian throe{�� pnor to opening.PLEASE NQTE:People are NOT allowed to sit m tbe pool area until the pool has baea u� and opened. POOL WATER TESTIl�G: The water must be tested for pseudomonas,total coliform aad stanclard plate counR by a Sta.te certified lab, atid submitted to the Health Depamnern three (3) days prior to opening, and quartetly thereafter. POOL CLOSIl�TG:Every outdoor in ground swimming pool must be drained or cov�red within s�vven('1')days of closing. ' FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health D�a�rt by the require�d Temporary Food Servic+e Application form 72 hours prior to the catered evem. These forms can bem o�tained at the Health Department. FROZEN 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 d4 so will result in the suspension or revocation of your Frozen Dessect Peimit unt�the above tetms have been met. OUTSIDE CAFES: ' Outside cafes(i.e.,outdoor seating with waiter/waitress sen+ice),must have prior approval from the Board ofHeaith. OUTDOOR COOKIl�TGt . Outdoor cooking,preparat�on,or display of any food product by a retail or food service establishment is prolu'bided. NOTICE:Permits run aru�ivally from January 1 to December 31. IT IS YOUR RESPONSIBIi11"Y TO RETC)RN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 1 S, 2009. ALL RENOVATIONS T"O ANY FOOD ESTABLISHQvIENT, MOTEL OR POOL (i.e., PASNTING, NEW EQUIPMENT,ETC.),MtJST BE REPORTED TO AND APPROVED BY 1'HE BOARD OF HEALTH PRIOR TO COMMENCEME1vT.' RENOVATIONS MAY REQUIRE A S PLAN. DATE: cS^ �� SIGNATURE: PRINT NAME&TITLE: � s S ` 09l2S/09 ' T . , �\ The Commonwealth o Mass h f ac usetts Department of Industrial Accidents �1lfrsN�llfe�s 6D0 Washington Street, 7`�Floor ' Boston,Mass. 02111 Workers'Compeosatioe ta4erance Aflidavih Bnitding/Plambi�g/Etectrica(Coatractors t p� name_ C � � � I , i addness- � � cl state• b hone �1 '\� � zi : work site location{full addcessl- ❑ I atn a hom�wuer performu►g all work myself. Project Type: ❑New Construction�Remodel ❑ I am a sole proprietor and have no one workin in an ca g Y P�ih'• Q Building Addition ,� ^Y� �a� \��/�, ❑ I am an einployer p�oviding workers'compensation for my ecnployees wo�cing on this job. e�J v� C00Ui0P N�l!' . . . . . � . . . . . . . . . . ��C� �� , . - . , . � . . . . . . .. . . � � tddl'dS: . . . . . . . . C�LY: - � � - . - � DhUiR!�.� . - . IBf CO. ❑;[.. ..-.:'.... : ;,; ;:_: .�.,' v:%:�->w , :;:.:. , ...:,:`. •--" `,- _x; ,-..:.,� r<r,n::F. m..�<�z .-ir�.s:-'13i�:'��i3*a'�. ..�r,. I am a sole proprietor,8eieru!costractor,or homeowa�(cirde o�re)and have hic+ed We contractasflisted below who have the following wotkers'compensation polices: 000u�v�uunc: addras:. dtw. nhate!!, _ �oe eo. , ' # • ,�,.� �y.,� � , ,.: � � r�,-'s��: ��;,`.: �v�aec: adiras: �Yc oLa�e� EY. �.. ,_ .. ._, � ::,�, ...�: .�, r . .. .: ... .. . . ' .. . . . . ..:. ._:._. . . .�:-. . .,-.,w: �.,.t ;'r..�.�.:�a �'"`�.-.��^z-�z'r..a'°.r�-..�'�€ti`�"�`�"!-4, z'`._:'•�'�''°��`y��,-`:�.�-_,.,,1�-"r',�... .:r . Faiarc M see�re a�sera�e as reqaioed aader Saetla�ZSA K MGL 132 eu lead t�Ite i�p�tMr�fa�i�iai pnal8a�f a�tp b i1.iM.N aod/�r �e Yeus �Pei�ea�at as wrg as d�Y peaalNes in tie form eta STOP WORK ORDE�aed a 8ne d�lA9.N M day a6al�st ne.1�da�Cud tlet a c�py�t t6h�taleme�t my 6e forwarde�M the Offiae�[ �t IYe DIA Hr ew�era6s v�er�a�r. I le ba+cby certrfy xnder ullie P�+� f diat tbe l�fonrradioa p+»v�ded eboae is bare rtxd � �te � a . Print name S Phone# ",�` �.� � � J �dal�ae e�ly do aot write f�tWs area to ie c�mpieted bY.cit�'K 1nen��eial - !��[tr1�� ; �j 12Rvidi..��[t�at ❑chut K�1e resps.�e b.ry�ea � p�oe . � pkKe 8; (�D�tU�� Peia� (��) � ' ; i