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Home My WebLink AboutApplication and WC ' �rt , TOWN OF YARMOUTH BOARD OF HEALTH �� . . � � APP�.ICATION FOR LICENSE/PEl�� -�2` ' �i �IQ� �� (�11 � � ' � , < < � , j�,p �� * Please complete form and attach all necessary da"'me �� ` ��it r 1 DEPT. Failure to do so will result in the return of+�ur a p ication pac . ESTABLISHMENT NAME: �/�FP� �/.�U�L+�I2/�-S �C TAX ID: LOCATION ADDRESS: - �U 1`' /2Y' �!�!• TEL.#: �S� �775�7/�' MAILING ADDRESS: � 0�67,� OWNER NAME: f��dUL l-��ls�'�� CORPORATION NAME(IF APPLICABLE): �� /� /��1� MANAGER'S NAME: ��F�Z- �q-�,��yj TEL.#: D �-�37 a2�� MAII.ING ADDRESS: ..� �`,�3-L�l_.�f+r�� .L�l� �IU�C/�-1Z.r�r�drif ,9?� �� 3 POOL CERTIFICATIONS: The pool sutpervisor 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. _ ---__�=,-----4--=� - - - - - -- — - � -�.`_ ..:-_— �. �__�_�__J� ��_ _ � _ ��____--�, 1. __f= N�/� 2. � 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 copies and maintain a file at your place of business. ' 1. /��1� 2. � �' 3. r� /� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certif'ied 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 this application. The Health Department will not use past years'records. You must provide new copies and maintain a�le at your establishment. 1. N�h- 2, �//�'1� _ _ PFR��N iN.�`HARC',R• �_ _ � — Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. '� /�s' 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. �`G�' 2. �� 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABW $55 _MOTEL $55 _INN $55 _�AIVIP $55 _SWllVtIv11NG POUL $8llea: ' _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. 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.KITCHEN $80 ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FEE PERMIT# i<50 sq.ft. $50 _>25,000 sq.ft. $225 VENDING-FOOD $25 �<25,000 sq.ft. $80 a��J� _FROZEN DESSERT $40 �TOBACCO $95 ��3 NAME CHANGE: $is AMOUNT DLTE _ $ I 7S. GQ *****PLEASE TURN OVER AND COMPLETE OTI�R SIDE OF FORM***** .�—_ —,,.� I 4 , e , � , ; ADMINISTRATION ' � � 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 company does not have a Certificate of Worker's Campensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND� SIGli1ED, OR CERT. OF INSURANCE AT'TACHED OR ✓,: WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED awn o arniou axes an iens must pai p r to ener wal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: YES ✓ NO 1V��J��I.� �P'v'� t3��€��a�.��'�'��i`r�i.��a�IIVYEi•fi'P� � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be 4 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 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. 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. � E FOOD SERVICE i SEASONAL FOOD SERVICE OPEIVING: 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 obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. i 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: _ __�t�i� "��+�e�-�a�-v��.�v�ra:ferfv�Ki�e�s se:vice),��l�v��:�:'ag�r$��:e�+o-��Q��lt�. OUTDOOR COOKING: 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 RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPR(�VED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �11� I I 2 Ul� SIGNATURE: �'�— PRINT NAME&TITLE: � l�!(, Rev.10l25/11 I � • i 1 � � cailirs� • � ' ` . The Commonwealth of Massachusetts Deparhnent of Industrial AcciJents an�esarr�r�..s 600 Washington Street, 7`�'Floor . .r ` Boston,M�sx 02111 � . Wor�ers'Compee�allos Inaarance Aflidavit:, ' � � �t idire�atln• Pleaie PItIW'1'te�ibi�► , . . .r : ,,`' '�� !� �;�. �� : �/�l� �` —�j 2� CG�2l� �1�/G a�s=---�� 11J,�—�iJu <S`�`��>`,' �� : �itY � ` /��i,�//�� siate: �f�T zio. ��7Jr�hone# L�� /U'��' ,, - - �, ,:: �. : {,,. -. -... . _ < . ; work site lceation(full addressl: .. ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity. [�'�I am an employer providing wotkers'compensati�foc my emplo ees wodcing on Wis job. . ,. _. _.,. _ __— _ � - - .�_ �..�: :y _ _ L,,s - _- ._ com me: .� , ,. , - . . • ,- __ _ �. —; .ua�: +7�iG�- J��D� v��f�2j�� : d�: C.t.�� //�iZ1�2��, O�'l/� C��7.� �.�#- �� s'—��;5"� �� , ,�.��. �t�c� �t�Z�v,,�o��DQ�/� �,� �.v e c a d� ��`v� � :..:, ., ; ❑ I am a sole praprietor,geieral co�tnttor,or homeow�er(cirde ane)and have hired the contractas listvd below who 6ave the following workers'compcnsation polices: �4mDtYY�1�'�� . . . . . . - . � . . � . ��f. 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