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Home My WebLink AboutApplication and WC '. t- � c��-��-�� '^� ► TOWN OF YARMOUTH BOARD OF HEALT�� "�"�°�� `=� � � � APPLICATION FOR LICENSE/P�1��VIIT-201 �"f�' DEC - " ?al � � �,, , � �S � 3�r�,;, � * Please complete form and attach a11 necessary�o'�uments y` �ecembe IS D 0 � Failure to do so will result in the return o�"your application pac . '` °f �-��=-�'��. ESTABLISHMENT NAME: TAX ID: � � LOCATION ADDRESS: 7S � �" TEL.#: t.�80 ; MAILING ADDRESS: : . f1. ' , . i e :. ; OWNER NAME: CORPORATION NAME (IF PLICABLE): �q� ('�,� Cp . MANAGER'S NAME: a�� /n�--- TEL.#: 5b 3�f OaaO MAILING ADDRESS:_�� POOL CERTffICATIONS: ; The poal supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Q�eiatar(sl ai�d attach.a copy of tli� s�i-ti��tio�t t� this fo1-m. ` 1. 2. Pool operators must list a muiirnum of two employees cun ently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. 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. FOOD PROTECTION MANAGERS - CERTIFICATIONS: ' All food service establislunents are required to have at least one full-time employ�ee who is certified as a Food ; Protection Manager, as defined 'ul the State Sanitary 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 file at your establishment. l. � 2. � �� PERSON 1N CHARGE: ' Each food establislunent must have at Ieast one I'erson In Charge (PIC) on site during hours of'operation. L 2. ' HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained 'ui the Heunlich 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 foiYn. The Health Department will not use past years' records. You must provide new copies and maintain a file at vour place of business. ..�. . ._ � . �. ..�. , _. _ - � � ,. . _ . . 2 . . ' 3. -r- 4 : RESTAURANT SEATING: TOTAL # OFFICE USE OlV'LY LODGI\G: LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERVIII# LICENSE REQUIRED FEE PERMIT# B&B S�5 CABIN S5� MOTEL S» iNN S55 CA1�IP S5� _S�V"I1�IIvIINGPOOL S80ea. LODGE S55 TRAII.ERPARK S105 �'�ZIIRLPOOL 580ea. FOOD SERVICE: LICENSE REQL�IRED FEE PERNIIT# LICENSE REQLnRED FEE PER�vIIT� LICENSE REQUIRED FEE PERVIIT t 0-100 SEATS S85 _CONTINENTAL S35 _NON-PROFIT S30 >100 SEATS S160 COMMON VIC. S60 t��IOLESALE S80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE REQLTIRED FEE PER'�IIT# LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER'��IT� _<50 sq.ft. S50 _>25,000 sq.ft. S2?5 VENDING-FOOD S25 � <25,000 sq.ft. S80 �(�/!-(3`{�I —FROZEN DESSERT S40 _TOBACCO S�5 �a�zE c�`cE: sis AMOUNT DUE _ $ 80.d� *****PLEASE TL'R\OVER A\D CO��PLETE OTHER SIDE OF FOR�T'***** � _ , � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the To�vn 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'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO , , � �r,��._.. . .,. . '�f�'��:�N��F}T�[��S�,QH�'T�G �S'�ABLIS$��NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy sha11 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 ofresidence 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 sha11 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 opemng.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 thereafter. _ _ _ _ _ _ ____ __ __ _ _. ��__�.__...f-: .,_ _ _ .� _ _ �. POC�L�I.OS��:�very outdoar in ground swimmmg pool r�iust be drained or covered within seven(7')days af 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.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 Boa.rd ofHealth. OUTDOOR COOKING: '' Outdoor cooking,prepa.ration,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 RESPONSIBILITY TO RETLJRN ' T'HE COMPLETED RENEWAL AppLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlibIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME& TITLE: : 10�06�10 � � �� ' �� ,p� � �\ The Commonwealth ofMarssachusetts � Departnie�et of Industrial Accidents � N�.'�Ni�fM�t 600 Washington Street, 7'�Floor Boston,Mas� 011ll Workers'Compensatioe Insnranee Aifidavih Baildiag/Ptambia�/Electrical Contnctors : �t iai�irm�tin: Ptesse PRINT le�bh . . j , n�: �0�U Qr� ��V�.e� � ' ' 7�_ R�_��---------=-- acidress• _ �iri �• 1��l��l(��1.�NA shate• !//� ----�P��p� Phoae# �IJ ,3� �(�8� _a_�.__ work site location(full address): ❑ I am a homeowner performuig all work myself. Pro ect T J YPe: ❑New Constnrction�Remadel Iama . . ❑ sole proprietor and have no one workin in an . ca i . S Y P�h' ❑Bwldu�g Addition ❑ I azn an empioyer providing kvorkers'compensation ormy:e�nn to ees w,orlcin :ou ' � �. P .Y th 'ot3. . . . , : , ds ____ ,. , S t�� li , v _._ - - — _ _ . _ fr _;�:.�_ • �., - _ __----- . --. _-�-_-_,.�- :�-�.�-�-� - _ _ -- _ _ _ _ � comoav nme: (�f1 f,� /1 • ��: sarvu as a�J e, ciri- oro�e# � ��. ee�' n i��ro �a WG�'7f7�/ D ❑ I am a sole proprietor,geaerai eoatractor,or�omeowner(circlt oiu)and have hireii the contractors�i�d below who have the following workers'compensation polices: comwuv ramc- addrds- ciri: uhoae# iesmasce co. � comn..r�ame: ad�r'as: e�� o�o�e N , _ _ -- =-�mn�iceea -- __�,_�- -�_�--��.�_ -- _ ooL�# A�1t M�d tlrK�rras� Failve 0�xeare�rrerase n reqeir+ed��dv SeeUo�2SA�[MGL 132 w k�d b fre h�p�aitl��f rnl�iul peaaNfn�[a�e�b f1.3M�N aid/K °se Ynn'�mprlro.�eet as weY as dvi peeaitlp In t6e[er�o[a 3TOl WORK ORDER asd a Qee et 5109.0�a day�afmt me, I owda�oud that a cspy et thh staoement may be forwaMdl�s Me dRice e[lave�tlptl�ss ot the DlA for aversse verlAeaMa. !do 6errby ce �eder NYe s awd nelt�ess ojperjwry t/Yet tlht Fajonrretloe provJde�abone Ls but d cornrt 5�� Date j� 7 ,I�V P�,t�. � �9� � Photte# af8etal uss osty do eot wrke f�this aro te 6e mApleted Dy dty or pwu aBieial ' ciry or town- permiNlice�e q OBaidina Department ❑ched[Klmmediale tespeme h reqaired ��°�°_�� OSdeetmes's Of��e rnafad perwa: p6eae N; �Heakl�Depatf�t t�sm+.zom� �a'