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Home My WebLink AboutApplication and WC � r -_ � �,`�; �>Mi��SroR-�5 -�� c r -� '►� TOWN OF YARMOUTH BOARD OF HEA . � F ��u�(��j�� r APPLICATION FOR LICENSElPERMI �, '� �` `J p; �""" � ' � �`� �i�� * Please complete form and attach a11 necessary doc ts '`' ecem er 1� �0�0: Failure to do so will result in the return of you``' ' plication pa et.HEALTH DEPT. � ESTABLISHMEN N E: ��\��a�_� TAX ID: �� I� LOCATION AD TEL.#. � '� MAILING ADDRE S: ' � OVVNER NAME: � "o CORPORATION NAME (ff APPLICABLE): - � MANAGER'S NAME: �c�� r`,� TEL.#��g'��. t\� f MAILING ADDRESS:.`�`� z '�i� �e�_��=��\�� c�'�,L��\ I � POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator, as required by State la�v. Please list the designated Pool Operator(s) and attach a copy of tl�e certification to this fc�rnl._ _ .____ �_ _._ : ___ _ __ _ . _�`; 1. � 2. � Pool operators must list a mnlunum of two employees curr•ently certified 'ui basic water safety,standard First Aid and Community Cardiopulmonaiy Resuscitation(CPR}. Please list these employees below and attach copies of employee � certificatians to tlus form. The Health Department will not use past y�ears' records. You must provide new I copies and maintain a tile at your place of business. i l. 2. i , �. �. � i i FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents a1e requued to have at least one fiill-tuiie employee who is certified as a Food Protection Manager, as defined 'ui the State Saiutary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a �le at your establishment. l. 2. ( � PERSON IN CHARGE: � ._ _. . , Eacli food establislunent must have at least one Person In Charge (PIC) oii site duruig hours of o�eration. � i l. 2. � HEIMLICH CERTIFICATIONS: ' All food seivice establishments with 25 seats or more must have at least one employee trained 'ui the Heimlich € Maneuver on the premises at all tuiies. Please list your employees trauied in anti-choking procedures below and E attach copies of einployee 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 LODGI\G: i LICENSE REQUIRED FEE PERIVIIT# LICENSE REQUIRED FEE PER\�IT= LICENSE REQUIRED FEE PER'�IIT� � _B&B S�5 _CABIN S» _140TEL S» ; _INN S55 CAi��IP _ _ S>j S�FIVIVIIN('TP(l(2I_--SRQea. _ '� _LODGE S�5 �TREIILERPARK S10� ��ZiIRLPOOL SROea. ' FOOD SERVICE: LICENSE REQUIRED FEE PERI�IIT� LICENSE REQLTIRED FEE PER��1IT� LICENSE REQUIRED FEE PERVIIT� _0-100 SEATS S8� _CONTINENTAL S35 NON-PROFIT S30 _>100 SEATS S160 COMIvION VIC. S60 ��IOLESALE S80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�1IT?? LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER�7IT� �<50 sq.iZ. S50 �'fl-Do� _>25,000 sq.flt. S225 _VENDING-FOOD S?5 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO SSS , �AJZE CHt1`GE: S1� AMOUNT DUE _ $ 50.00 ' *****PLEASE TLR\O�'ER A\D CO�IPLETE OTHER SIDE OF FOR�I'"**** ' RECEIVED OCT 2 51010 � ! � � >. ' ADMINISTRATION i I # 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 campany does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE � AFFII3A`'IT MUST BE COMPLETED AND SIGNED� �R � , � CERT. OF INSLJRANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to rene�val or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ; YES NO i ' iVIOI"EI,�AlV� O"�HER I.D�UGiNG��'I�AI3ii.YS�Iii��EI`T`YS -- -- - _ . 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 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 opening.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 'I thereafter. ___,._____ _ ___.� ._.�--_�- _ _ _, _ f _ __ _ _ ; POOL 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 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 Town's website at www.yarmouth.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: �I Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ' _ _ __ OUTDOOR COOKING: I 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 RESPONSIBII.ITY TO RETtJRN THE COMPLETED 1ZENEWAL APPLICATION(S) AND REQUIIZED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOA1�D OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; DATE: SIGNATURE: PRINT NAME&TITLE:��..�, � �� \��\�,�-- 10 06 10 � I i tS� L . `�� .. The Comnionwealth of Massachusetts Depart�nent of Industria!Accidents ' NAfei Kiwst�ilM�c 600 Washington Street, 7`"'Floor Boston,Mass. 0211I ' Workers'Compensation Insorance Affidavit:Bailding/PlHmbin�/Ekctrical Contractors Anollea�t htr■re.�tM�- Pl�ase PR4V'1'kQlbh ' namc: �'C��UL—d�� r,�.��S� ��V�� `7\�,� ii address: \\.�. I --�---------- ----- ---- ---------- citv�A; �i�1��C`caC�cl�� state• �� zio 6�r`� �s] P��5��`�� I wnrk site location(fiti]azldressl_ �! ❑ I am a homeowner perf'ornung all work myself. Pioject Type: ❑New Construction�Remadel I ❑ I am a sole proprietor and have no one working Yn any capacity. ❑Building Addition � �, I am an employer providing workers'compensation for my employees wor�Cing on this job. com�uv nme�w�� Q �� t��''\4�� `�� ' � .� �� „� �aa�: .�c�c ��. -�� _ _ _ � �ic,�: �c�� C\� �`c�.`c�.�Z� ��r , ins�see ca��C`�� ➢ 4�'Y1,� c►�n��y�_��--�� —.�.� ��i ❑ I am a sole ; \ proprietor,geaersi costractor,or homeo�vner(circl�one)and have hired the contractocs listed below who:have I', the following workers'compensation polices: , COIUDlYY 9�ffi!• . � . � ',. . ��lSf' . - . . . � . CILY: DdOs!$ I0ER�6CY CO. . # commev oame: addreas: citv- oro�e N . _ -____ _ ��nua�ce co. ��# . . _ _ AM�MIiY�W�r,et�� Faiim^e Ir see�e eeverase n reqaletid s�ler Seetlo�2SA�[MGL 132 caa k�d b tYe isp�aitlH�f QioLal pe�aNfn�[a Sae�b S1,3N�M aad/K °K ydro'le�Prboameat as weY as dv�peaaltles In t6e fer�a(a 3TOT WORK ORDBR a,d a Qee d 310s.6!a dar a�alast-e. 1 aedasd�d th�t a cepy o[tih sta�emeat mar 6e forwarded os tee Oalce a[1we�tl�Wss ot t6e DIA far c��eraae verlentle�. !do benby certify rader NYr polws awd ptnalties ojperf�ry Nket NYe i�forwiotlon prov&/e�oboae fs true awd corre�ct � s;�� ` �;� � ��,� � �t� , Print nanx �\ '�� Phone��'�\- '��Q� ofBciai aac oNy do not wrke Is thh aro ta be rn�p{eted by dty or lrwn oBkia� . dty or tawp• pennif/liceme ll �Baidina Depar�ent ❑c6ed[Himteediah me h D�e�iaa Board �Ps rc9uired �Seleetmn's OfB�e contad penen. ��1kp�rdee't t�e x�.mao�� p6o■e M- QOt6Q