HomeMy WebLinkAboutApplication and WC/ `
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� TOWN OF YARMOUTH BOARD OF HEALTH G
� APPLICATION FOR LICENSE/PE � � x�r� �-� f :,_�
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* Please complete form an d attac h a l l necessary d�me ` I�e
Failure to do so will result in the return of your application pa ���'
ESTABLISHMENT NAME: �v�..� 1�SL,�+�-n1� Y:L��.� ['�,��� T X ID•
LOCATION ADDRESS: �/g'/ ���/� �sL,r�.v� rz TEL.#: 5��- �°�'g '��I�
MAII.ING ADDRESS: "�. � C • .F�: ''�
OWNER NAME: .�1!�'• C�'a,yc,✓ f�SS• i
, CORPORATION NAME(IF APPLICABLE): ;
MANAGER'S NAME: TEL.#: '
MAII.ING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form. __ '
i
1. ,�A Y�' cS%t�'�.YSoN, �idL�r 1 rs. .1 i G. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid �
and£ommunit�Cardiopul�e�3��s�s�ita��er�{Cg�}-�l€-as�s��.hes� . �t�c�i_-cegi��--e£-- - �
employee certifications to this form. The �Iealth Department will not use past years' records. You must
provide new copies and maintain a�ile at your place of business.
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1. n�h�mcS C`RoCkF�n• 2. '
3. „i�,�mc.� ,/=�RR�.�I/ 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Cade for Food Service 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 new copies and maintain a�le at your establishment. -
,:..�-'
1. 2.
YERS2I�I Il��HARGE; _ _ _ - - __ - _ ._ _ , __ _:----!
- __ _ _
Each food establishment must have at least one l�erson In Charge(PIC) on site during hours of operation.
____
1. - - _ 2.
HEIMLICH CERTIFICATIONS:
All food 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 employees trained in anti-choking procedures below and ';
attach copies of employee 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.
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RESTAURANT SEATING: TOTAL# '
OFFICE USE ONLY ':
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_iNN ��� _C��I� ��� 2• �1%vliviMllvCi YUUL $xiiea.,�e� �
-----_-_7.C)Ri'iE-- _ _$55_ ��_.�— --._�_�ruATi.F.R PA�K R1�5__--=.=...s WHiRd..P_n�.___. ___$$Oea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 ,
_>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80
RETAIL SERVICE: —RESID.KTTCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sg.ft. $225 _VENDING-FOOD $25
_<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 1 bo ,o 0
**�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
ADMINISTRATION i
;
Under Chapter 152,Section 25C,Subsection 6,the Town of"�'armouth 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'S COMPENSATION INSURANCE ',
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED '
. 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. PI.EASE CHECK '
APPROPRIATELY IF PAID: '
YES NO
1VI(�'�fi'EI,S Al�'� f3TH�i�Lt��uCTING�S'��3LISIi�viENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be !
limited to the temporary ancd 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 I
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. �
POOLS
POOL OPE1vING: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 �
prior to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected
and opened. I
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.
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 inspected 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:
----Qz�is�der_.�f�.cli,��,-d3�l�S�lx caaYin.�tx�ith W�l11�'/vc1�1�PSS S�-�/L�P)>m�.�st l���e���ov��fram t�e L�ar�1 af H��t�h.
;
OUTDOOR COOKING;
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. '
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NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. I
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ALI. RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POGL (i.e., PAIlV`TING, NEW ;
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR �
TO COMMENCF,MENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
DATE: SIGNATURE:
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PRINT NAME &TITLE: .;l,c��s zl . �rirz�r%1 ��'.4.o.a.s�.,�,rr. �
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Rev.]0/25/ll �
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DEC-29-2011 (THU) 12: 05 P. DO1/001 '
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'���'a� CERTIFICATE OF �.tASiL.l�ll INSURA,NGE �"'���""�°'""",
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THIS CERTIFlCA7E 15 ISSU�D AS A MA77�R OF INFORMATION ONLY AND CQNFERS NO RIGHTS UPON THE CEi7'I'IFIGA7� l-IOLDER THIS
CERTIFICATE DOES N07 AFFIItMATIVk�Y d� NEGA'CIVELY AMEND. �Xl'EN� QR AL7� 1'H� COVERAGE AFpOItqEO �Y '1'H� POLICfES
BELOW. THIS C�R'1'IFIC-�►'�� OF lNSUR�►NG� DOES N07 CONSTl7UT� A CON7RIICC �k'Y'v+r�N TH� ISSIJING 1MSUREIt(SJ, AUTHORIZED
REPRES�N"i'A71VE OR 1>RODUC�R,AND THE CER1'J�ICA'1'E HQLI�ER. .
IMPORTANT: if the certi�cate holder is an ApqIT10NAL IN5UR�0.the pvlicy(ies) must be endorxd. !f 8UBRGGAYION IS wANEO,subject to
the terms and COnditi4n5 of the pol{cy,c.ertaln ppfiCies Cnay require an endor5eme„i. A statement on this certificate doeu aot coMer�ighLs to the
certifiCae�hqidar in Ilau of sueh andoraom s.
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CERTIFICATE HOLDER CANCELLA710N
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$HOULa ANY�P'1'li�ABOYE DESCRIBED POLICIES BE GWGELLEO��FORE
Town of Yarmouth � THE EXPiRAT10N W1TE THERE4F, NOTICE YY1L� �� pF1,1V�R�D iN
gQa��w����t ACCORDANCE WITH THE POLIGY PRQVI�1pN5.
1146 Route 28
So Yarmouih,MA 0�6B4 nurnoR¢eo rsE�eserrrarnc
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