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Home My WebLink AboutApplication and WC ,. ' ` . TOWN OF YARMOUTH BOARD OF HEAL1'�i G3 C�C�Cs 0 d�D � AP'PLICATION FOR LTCENS Y� , -�#�. t ,,,r * Please complete form and attach all necess�.:' * o � � � t � ��` JA N 2 9 2 010 Fail.ure to do so will result in the retu ' f n a �C��' �.�_� �_�_��_..,- NAME OF ESTAI�LISHMENT: ��N �ca�S ' TEL. #�08-394--i'Zc� LOCATION ADDRESS: 235 �.� �r=.��_„-ru <'-,.,. y�,k..�.n�,Lr�-, � M�+ o��y MATLING ADDRESS: ��--�� OWNER NAME: ��2--T �`� las� Se, T�X ID (FEIN or SSNZ• � CORPORATION NAME (IF APPLICABLE):_ � ��a MANAGER'S NAME:___ �a�so�_F�.�,qc TEL. #� �,94 -�4 24 MAILING ADDRESS: 23� �Z �r�� r��-.i � y,o e-+�n�scN� Mp. o2�c�y, POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated Pool Operator(s) and attach a co�y of the certification to this form. 1. 2. Pool operators must list a minimum of two emp loyees currently certified in basic water safety,standard First A.id and Community Cardiapulmonary Resuscitation(CPR). Please list these employees 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 mainta�n a file at your place of business. �. a. 3. 4. FOOD PROTECTION�vIANAGERS - 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, 145 CMR 590.000. Please attach copies of certification to this application. The Heatth DepRrtment will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. ��(L-�T �l �A-� �� S�2 . 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1._ �o�� T. J�,sV�� S�., 2. HEIMLICH CERTIFICATI4NS: All food service establishments with 2S 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-chokmg procedures below and attach copies of employee certificarions to this farm. The Health Department will not use past years' records. You must provide new copies and maint�in a file at your place of business. 1. �. 3. 4. RESTALTRANT SEATING: TOTAL# �3 OFF'�CE US� ONLY LODGING: LIC�NSE REQUIRED F�E PERMI�'# LICENSE REQUIRED FE$ PERMtT# LICENSE REQLTIRED FEE PERMIT# „`BBcB $55 ^CABIN $55 _MOTEL $55 �1NN $SS �GAMP $55 �SWIMMtNG POOL �80ea. ,�,LODGE $55 ____'TRAII,ERPARK $105 WHIR.T.,POOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIR�D FEE PERMIT# _„�„0-100 SEATS $85 (U�O'J7 �CONTINENTAI, $35 ___�_� �NON-PROFIx $30 >100 S�ATS $160 I COMMON VTC. $60 � 0��3 ____WHOLESALE $80 RETAIL SERVICE: �RESID.KITCHEN S80 LICENSE R�QUIRED FEE PERMTT# LICENSE REQUIltED FEE PERMIT�! LIC�NSE REQUIRED �'EE PERMIT#s _„<50 sq.R. �50 >25,000 sq.ft. �225 �VENDING-FOOD $25 ,�<25,000 sq.ft. $80 _�'ROZEN DESSERT $40 TOBACCO �55 NAME CHANGE: �is AMOUNT DUE _ � [�_S OQ , "****PLEASE TiT12N OVER AND COMPLETE OTHER SIDE OF�'ORM"*"** ..... ,. .,, � a .t . ... ,_ . . . � c .. ADMINISTRATION �Jnder Chapter 152, 5ection 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any liccnse or permit to operate a business if a person or company does not have a Certifica.te of Worker's Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATTON 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 yaur permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations af MoteI or Hotel use,Taransient ocaupancy shall be limited to the temporary and short term occupancy, ordinaril�and customarily associaxed with motel and hotel use. Transient occupants must have and be able to demonstrate that they mairnain a principal place ofresidence elsewhere. Transient occupa.ncy shall generally refer to continuous occupancy of nat more than thirCy (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 sha11 not be considered transient. Occupancy tha.t 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 Transienit. POOLS POOL OPENING:.All swimming,wading and whirlpools which have been closed for the season must be insp� by the Health Department prior to opening. Contact the Health Departmetrt to schedule the inspection thre�(3)days pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m 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. POOL CLOSING: Every outdoor in ground swimming paol must be drained or covered within seven(7)days of clvsing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yaxmouth must notify the Yarmouth Health Departmern by filing the r�uired Temporary Food Service Applica.tion form 72 hours prior to the catered 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 susper�sion or revocation of your Frazen 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmernt is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMFLETED RENEWAL APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOI. (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY 1'HE BOARD 4F HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE P . DATE:�r�, Z��iv SIGNATURE: �„ PRINT NAME&TITLE: ��T. .�Y t� �.. C,�F /�y� 09/25/09 . w • � � The Commonwealth of Massachusetts Department of lndustrial Accideats �asflin�s�al�rs 600 Washington Street, 7`h Floor ' Bostoa,Mass. �2111 � Workers'Compe�sation Insoragce Atiidavit:Baiiding/PlambingtEkctrical Contraetors A��e�twt ief�rmaR[�t Pleaar�PRINT leQibir : n�- %�-r- r T J -�S►�.v s2 aaa�s: 3�1 ��v.�� 5-�-• citv �ca ��'N�5 state• '�YJ zip• �Z�C� phone# '"1'�4 2l2 21»� work site iocation ffull addressr ❑ am a 6omeowner perforn�ing all work myself. Project Type: ❑New Cons�vction QRemodel [�]I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an e�nployer providing workers'compensation for my employees wodcing on this job. comaaev�me- �C��I ��CAv�S � iddrtss: 2�3�'�"#� 2- . li.��--��-T'�� IA�h� ciri: �je�. `1 ►o�..v�/�t�� rT 3-> � �A. �Zl'oC � uhoae#: .G,�--?��-4� - 12 CX� Ira co- '��,�J.--Y°` O 0 l '-� 02 .�;;� ... �., < `�. . ��:f:::: �.:�.`�. ..�,. Q I am a sole prapnetor,geaerai eo'ttactur,or�omeowner(circle o�re)and have lured the contractocs�listed below wl�have tl�e following workers'compensation polices: comm�v aame• address: , citv n�aae!�- _ ieaarasce co. # � .�.>s„. ..,- - _ . _ .. ,: -�. , ... .. . . .,..: ....;: - �.:.. { ::; �,.� �;�=� y.;.:: l9�WE4 O�l!' . �!!E' CI�S: DkOR!�' �Ole7�CEt0. ,. - � ,:,., . _:. ,.., ,...,.., .� . .: i�_:� �.,� ``:: :�'' -�� z x':: x "',`:�. �....'.�.-;�i)..'7.�4tYi�'...�1. ,�'^� 5rs`4x��'�.��r'> . Failve d see�me awera�n reqi�+ed oder 5ectlo�ZSA�t MGL i52 eu kad b fYe��f eri�i�d pmaMks da�e�p b S1,SA�AY addhr o�e yan'Ue�prieeosest as wee as dH peealtla lu tie for�st a 3'POr WORK ORDBR aad a 8ue sf 5100.Y�a ospg�f t1��ta/me�my be fenvaMed�s tie O�ce et �J'��se. 1 ndmlaad that a 1ave�tlgaWas otUee DIA tor eavsrage veri�eatlN. L 10/�d+tby cer(ify rra e ate nfPtr}+rry tAet e iwfor�aa(lon pravided aboae ts h+te awd oorrert s,� � � J r„v� . 2�3 .20�� Pr;nc naa�e k�-�L � �S1L�t ��2 Phor►e# �1'2 4 -2�'Z- 2,0'7`-) o�cial a+e aely de aet wrke�t�s arn to 6e camPletsd 6Y.cih'ae tawa�official dly or bw� ; P�g RRoitdiss j�a1'�ent p.�ect tt�me��e�sme is reqo•uea _ �B°'re ps��:oeaa �� c �,��,� P�x�, flOttQ