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Home My WebLink AboutApplication and WC " .. TOWN OF YARMOUTH BOARD OF � Q:°; ° o AP'PLIGAITON FQR LICENSE • � h 2 . �'�`. q � � �� - � ��! � lJ L�� ! * Please complete form and attach all necess � o "` s by Decem r 2009. . Fai�ure to do so will result in the return af your application pac et, utr � . NAME OF ESTA$LISHMENT: TEL. # �-�(-�� LOCATION ADDRESS: `' MAILING ADDRESS: OWNER NAME: T D FE or CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: --�'H1�� lA� TEL. #�� MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor mast be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to th�s form. 1. 2. Ponl operators must list a mmimum of two employees currently certified in basic water safety,standard First Aid and { Com�nunity 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 m�intain a fde at your place of business. i ]. 2. 3. 4. FOOD PROTECTTON�IANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ' Please att�ch cnpies of certification to this application. The Health Department will not use pAst years'records. You must provide new copies and maintAin a file at your establishment. i ,� � 1. �" � 2. � PERSON IN CHARGE: _ - - -- -- Eac��ond establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1- �,Y�-'�' .� ��."1� 2. HEIMLICH CERTIFICATIONS: All foad 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 emmployees trained in anti-chokuig procedures below and ; attach copies of employee certifications to this farm. The Health Department will not use past years' records. You must provide new copies and maintain a file �t your place of business. 1. 2. _. 3. : 4. ' RESTAURANT SEATING: TOTAL# �-� OFFICE USE ONLY LODGING: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,�B&$ $55 �CA.BIN $55 _„MOTfiL $55 INN $55 _CA1�4P $55 �SWIMMITIG POOL �80ea. �„LODGE $55 p.�O �TRAILERPARK $105 _WHIR.LPOOL $80es. , FOOD SERVICE: LICENS�REQUIRED FEE PERMIT# LICENSE REQUIItED f�E PERMIT# LICENSE REQUIRED FEE PERMTT# �0-100 SEATS $$5 � O�I � _GONTINENT'AL �35 NON-PROF'IT �30 >100 SEATS $160 �COMMON VIC. $60 � _.._WHOLESALE $80 RETAII.SERVICE: -�RESID.KITCHEN �80 L,IGENSE R£QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LTC£NSE REQUIRED FEE PERMIT# _„<50 sq.R. $50 >25,000 sq.ft. �225 �VENDING-FOOD $25 ,_;_<Z5,000 sq:ft. $80 _._.FROZEN DESSERT $40 TOBACCO $55 NANI�CHANGE: sis AM4UNT DUE _ $ Z OO. o 0 ""*""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"** I ___ �� , ,: _� f i s , ' ADMINISTRATION a � � Under Chapter 152;Section 25C, Subsection 6,the Town o€Yannouth is now required to hold issuance or renewal of any licens� or permit to operate a business if a person or company does not have a Certificate of Worker's Cvmpensation Insurance. THE ATTACH�D STATE WUItKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �� CERT. OF INSURANCE ATTACHED � �(��Q� ' oR P WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmauth taxes and liens znust be paid prior to renewal or issuance o£your permits. PLEASE CHECK APPROPRI�4TELY IF PAID: YES � NO MOTELS AND OTHER LUDGING ESTABLISHMENTS -- TRANSIENT OCCUPANCY: For purposes af the limitations of Motel or Hotel use,Transient occupancy shall be i, limited to the temporary and short term occupancy,ordina,ril�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 accupancy sha11 generally refer to continuous occupancy of nat more than thirty (30) days, and an '' aggregate of not more than ninety(90) days within any six(6)manth period. Use of a guest unit as a residence or ' dweliing unit sha11 not be considered transient. Occupancy that is subject to the collectiott of Room Occupancy ', Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transie�nt. ', POOLS POOL OPENING:All swimming,wading and whirlpools which ha.ve been closed for the season must be insp� by the Health Department�prior to opening. Contact the Health Departme�t to schedule the inspection three(3)days pnor to opening.P]LEASE NOTE:People are NOT allawed to sit in the pool area until the pool has been inspected and opened. POOL WATER 1'ESTING: 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. _ ._ POUL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7}days af closing. FUOD SERVICE CATERING FOLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme,nt by filing the required Temporary Food Service Application form 72 hours prior to the cafered event. These forms 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 suspen�sion or revocation of your Frozen Dessett Permit wrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seatin�with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOHING: Outdo_or cooking,pre�aration�or display of any food�roduct by a retai_1 or food service_establishmerrt is�rQhibi�e_d. __ _ NU1"IG'E:Pemuts run annually from January 1 to December 3 l. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY Ft'lOD ESTABLISHMENT, MOTEL OR POOI, (i.e., P,AINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR T4 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: � PRINT NAME&TITLE: 09/25/09 _t � � ' .� 4 . y �\ . � � The Commonwerrtth of Massachusetts Depa►�ment of Industrial Accidents I �N�� ' 600 Washington Stree� 7�k Floor Bustoa,Mass. 02I1� Workers'CompeasalloH Ia4uraece AtSdavit:gmlding/p�embing/Electticat Coatractors AnaNe�rt iwfir�n�li�: p'lease pItINT le�bl� �: ��"1Y1 �1�- �t�� c�CIU a�s: ��1 �`y'�A►►�� Y�1C ; citY I� �9`\I��U U 1 V'1 state• �� zip• O_ ��_ph�e# �U� ` 1 I I- �� inrork site location(full add�essl• � _[� I am a homeownec'performing all work myself. Project Type: ❑New Constivction�Remodel �'I am a sole proprietor and have no one wotking in anY caPacitS'• ❑Building Addition ❑ I am an�nployer providing wo;ke�'compensati�for my employees working m�this job. co�v e�me:__ _-- -- -- - - - _ — _ _ _ .. - _ -- _ addtrss: citv: o�6a�ae IY- oo. ❑` , ::-�. �F,::; �:--•. � c:.. ;. .,.` _..= , . s.: _.:::� ..F..�, _...:?� �:�-f.��'s�.�,�,:.:> I am a sole prapnefor,geoera!c�tractor,or homeewaer(�arde are)and havef lured the contractors li�ec1 below who have the following worke�s'compensation polices: oomu�v aamc: add�sa: dtv : ��, _ . _ ies eo. ,. ^� .�,:...r . �. ,. .� ,�s; ,t�', r_"��s�� 7 Y�!' �: �4*: , �� --- -- - ---�— - — __-- —-- -- - . — _ ___ ,. .....; .. �. • - - � � � �`' _,:.- �.c:s :r, -� :� ... . .. . . � .... -. , . .�c ;'�..�:.' �a..-3`..�t'f az�..�,�.:��r.,#.�?k`�i�":�., ��;��±�._kr,�,�•r�.._ �. .:s Faiare M xcQ+e e�saa�e as�'e9dral,,�der Sceliat 2SA�t MGL 152 n�Ind N IYe irp�t�f a�ial peal�es�Ea ie�1�i1,SM.N a�dla�:+ w�e�'s'i�t�t�t a�weH u cM peaalqa�tie fie��f a 3TOr WORlC ORDER a�d a Bae�t f10�.N a c�p9�[lih�ta��y.be f�rwn+ded os Ne Omoe�f lanatlptlo�s�t IYe D1A tor cwasse vai�tl�, �Y��e.I��d 1i�a I l014enby rurdee Mre pr}ie.s RwdPe+whi�'of pt�iwy tl F�t dFe lwfenrrallon pt+ov�ded aboae is bxe aid ca� s;�°�°"� n� �2 2)--� Pti�namc �Iv� �, Phoae# .�'l�.�� :�`3�'��?. �dal ase�aiy d�aet w�ite�t�area t�6e c�pi�f�ed by.citY or pws��ciai . _ e1t��r t�: ;.�8 n.a�.�� cYaic if�me��e re�psve is reqi�ed _ []Sdec6�a O�ae . . t�� pto�e S; ('� �� !