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Home My WebLink AboutApplication and WCi , � - ' P ERocK-�EIGH'TS ASSN. i.;� -. �� . . �, � �� TOWN OF YARMOUTH BOARD OF HEALTH �,J�j l�L,J = APPLICATION FOR LICEN5E/�F�VI��2�l �`, ._.o (� * Please complete form and attach all necessa ��c �=:� s "�. � ce� er��2111��"�� Failure to do so will result in the retun�f y i n p e�,IEALT H DEPT. ESTABLISHMENT NAME:_ ��'� ��Xt' �,�"/��75 ,�5�/�1'.�-%/a� ��1�TAX ID: � ,� LOCATION ADDRESS: ,d�tr� ,�e�.� �� TEL.#:��b�'-�� -ct7h�� . MAILING ADDRESS: r .Ga. t�X 7ei1 S`L?L��/ y,�,�,,�T� !�l/h d-1CL�f OVVIVER NAME: " � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool s�cpervisor must be certified as a Pooi Operator,as required by State la�v. Please list the designated Pool O��ra�orrs) and ��tach��y Q�the cert�c�tio�ta th�s fon�3. 1. ��c�i�l�1�Sl�¢h" �d�Ls 2, Pool operators must list a muiimum of two employees cumently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees belo�v and attach copies of employee certifications to this form. The Health Department will not use past years' recflrds. You must provide new copies and maintain a �le at your place of business. 1. �� 1 f��b �y l�c�-2D 4� �✓�'�/Li�1� 2. �� 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishrnents are required to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined 'ui the State Sanitaiy Code for Food Seivice Establishments, 105 CMR 590.000. Please attach 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 rood estabiislunent must have at Ieast one Person In Cllar�e (PIC) on site duruig hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food seivice 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-chokuig procedures below and attach copies of employee certifications to this foi7n. The Health Department will not use past years' records. You must provide ne�v copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERVIIT#� lICENSE REQUIRED FEE PERIVIIT� _B�:$ S55 _CABIN S55 _UIOI'EL S55 _1NN S55 _CAMP S55 _ I S��'Il�L�III�IG POOL S80ea. — DO� _LODGE S�5 ,�TRAILER PARK 510� ��'HIRI.,pOOL S80ea. FOOD SER�'ICE: LICENSE REQUIRED FEE PERMIT z LICENSE REQUIRED FEE PER��IIT z LICENSE REQUIRED FEE PERtvIIT Y _0-100 SEAI'S S8� _CONTINENTAL S35 _NON-PROFIT S30 _>100 SEATS S160 _C01�LMON VIC. S60 «'HOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�tIT.# LICENSE REQUIRED FEE PER��IT� LICENSE REQLTIRED FEE PER'bIIT# _,<50 sq.ft. S50 �>25,000 sq.i�. S225 VENDING-FOOD S25 _<25,000 sq.t�. 580. _FROZEN DESSERT 540 TOBACCO S» �a`zE c��cE: sis AMOUNT DUE _ $_�p,pO ***�*PLEASE Tti'It_\OVER A\D CO�IPLETE OTHER SIDE OF FOR�i***** r ,, � i 'Ii � � �.��. 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 Compensation Insurance. THE ATTACHED STATE WORKER'5 COMPENSATION INSURANCE i AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � � CERT. OF INSURANCE ATTACHED � OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Towr�of Yaxmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO � . , . � MOTELS AND OTHER LODGING E5TABLISHMENTS 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 sha11 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 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 De�artment 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. ; € PO��.CLC)SrNG; Every-outdoor in ground swimming pool must be drained or covered within seven(7) days of � clasing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the �-Iealth Department to schedule the inspection three(3) days prior to opening. CATFRING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required 7,empprary Food Service Application form 72 hours prior to the catered event. These forms can be obtauied at the 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. OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. - � OUTDOOR COOKING: t�►uidoor cooking,preparation,or display of any food produc;�by a retail nr food set-vice establishment is p�ohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETtJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS��YVIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY QUIRE A TE PLAN. f DATE: ��C SIGNATURE: %�..�C � ' PRINT NAME&TITLE: �-LP� ,� .CC�it�i�� ,/S T j/L�'K I��i�C /t��'�'w?S �IS'SGr�- � � 10'06 10 t,; ; - T ,�.\ The Commonwealth of Massachusetts Departmeat of Industrii�t!Accidents ' N�eI N�,�i ' 600 Washington Street, �k Floor . Boston,Masx 02111 � . Workers'Compensation insaranee Al�idavit:.ga��ding/Plambieg/Ekctrical G�nntracturs• - . , .; �t i�firentin• PiL�'f'k�iW�r . name: �7�Cl� ��'� �i�fi/G".�fTS �5'�'L1C7`/�T�QIJ✓ ��s: ��c Z9�-------1�� Gr��-��_--- c�_ t'l��Ti� ��,��'7�l1/ state• F' e� zio �'N � ohone# 1Lj� 3/`�/��t�� work site Iceation(full addressl- ❑ I am a homeowner perfornung all work myseif. Pro�ect Type: []New Construction�]Remodel ❑ I am a sole proprietor and have no one working tn any capacity, �Building Addition ❑ I am an employer providing workeis'compensation fa�my employees working�this job. comoaiv nme- addrds: cStv: ��J� _ �e M tns co� C�/� # ' ❑ I am a sole ' g , ;. prapnetor, eaeral co■tractor,or homeo�vn (carcle one)and have hired the conhactors listed below who bave the.fiollowing workers'compc�sation polices: �� D� �� aa�: � �� : i,�.�.a ro. ��' l� � � • �: ��: �x - ____ _ _ _ __ _ ��._ _ __ _ __ _ wwd�.+�r.n�r..er� odt�# FaHve b xeare awase as reqaGnd»dv Seetls�2SA e[MGL!32 eu kad b t�e ' °k Yan'bpM�ee�eat a�weY as dvi peealtles lA tbe ferr o[a 3TOT WORK ORDBB�Qnc dQ 318s N��[a IIne�b S1,SM.N a�d/K ,� c�py et tik staleme�t m�y be forwarded�s tAe Oatce e[I�of t6e DIA far c�verate veriAeatlw. Y��e. 1 mderslaM th�t a ' !do IFe�by ce xnde pe! and peneldea ofP��+�rJ't6ot NYt iwfonwaBoe prov7der obone fs trwe awd c»rnct 3iBnatuce �/Z/� Date _ �/"`��°'/�L� Ptint name ��LI�� - �� Phone t� �/��.�L��, oBcial ax oaly do nM wrke te this aro te 6e rna�pleted bY dtp or Nwn oBk3a1 _ eity or tewn: ` permitlikeme p QBnidiea Deparimept �c6ed[if immediale re�penx is reqaired 0��°�a�+'� - 04e1ectme.'s Of6ee rnetact penon• ��#� �Q De�arheeat c�.oe s�,mm�. I I