HomeMy WebLinkAboutApplication and WC� S�Foo�
�� � �� r TOWN OF YARMOUTH BOARD OF HEA��T�" 'R,�`�� ���LQ�!�DD
� APPLICATION FOR LICENSE/PERM� 0 1 +
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* Please complete form and attach a11 necessa��dt��zri€��q'�ece ber IS 2010.
Failure to do so will result in the return���ou��pplication ck . DEPT.
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ESTABLISHMENT NAME: �a�� o� /� TAX ID: ����'�� �
LOCATION ADDRESS: cS t " TEL.#: �F�' 77S –o o�k
MAILING ADDRESS: .r n s� • �✓a'r�o v�
OWNER NAME: �s' �� (/Q vs ��
CORPORATION NAME (IF APPLICABLE): C'i,p � L'o� r� Se� 7�a� /i'.•E/� � Lc
MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
; POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desi�nated
Pool Operator(s) and attach a copy of the certificanon to this form. __
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Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Community Cardiopulmonary 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
i, copies and maintain a file at your place of business.
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3. 4.
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1 FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please-attach copies of certification to tlus application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
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' Each food establislunent must liave at Ieast one Person In Charge (PIC) on site duruig 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 emplayees trauied in anti-chokmg procedures below and '
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide ne`v copies and maintain a �le at vour place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
�FFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PERMI7� LICENSE REQUIRED FEE PERI�IIT#� LICENSE REQL�IRED FEE PERIVIIT�
_B&B S55 _CABIN S55 _MOTEL S55
_INN S55 CAMP c55 S��'I:VI!bItNG POOL SEOea.
LODGE S�5 �TRAII,ERPARK S105 �u'HIRLpOOL S80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PER��IIT� LICENSE REQUIRED FEE PER�IIT�
_0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30
_>100 SEATS 5160 CO1vL'�ION VIC. S60 `'��IOLESALE S80
RETAIL SERVICE: —RESID.KIrCHEN S80
LICENSE REQUIRED FEE PER'VIIT� LICENSE REQUIRED FEE PER��IIT,~ LICENSE REQUIRED FEE PER'�fIT�
_<50 sq.tt. S50 >25,000 sq.ft. S225 _VENDING-FOOD S25
, ( <2�,000 s .ft. S80 I�O?/?/ _FROZEN DESSERT S40 TOBACC 55
— 9 O S
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���cx��cE: sis AMOUNT DUE = S 80.00
*****PLEASE TLZL\OVER A\D CO�TPLETE OTHEIt SIDE OF FOR`1*****
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ADMINISTRATION
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 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. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AI'V17 OT`HEIZ Lf�DGING ES�ABLIS�MEI�TS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shaU 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 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. a 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. !
POOLS E
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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
thereafter.
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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.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 Board ofHealth.
OUTDOOR COOHING:
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 RESPONSIBILTI'Y TO RETURN
THE COMPLETED RENEWAL APPLICATION(5) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQLTIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: // /� a SIGNATURE: ����
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