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Home My WebLink AboutApplication and WC R '°° � TOWN OF YARMOUTH BOARD OF HEALTH `. 5��i:�` � ��%, � � � APPLICAaI'IQ►N FOR LICENSE/PERMIT-�,201 �, �,,,,,e �t a,.�!i� .. �. � ;�.r, t,,,,, ) 1 :_ � ;�ic� ; * Please complete form and attach all necessary docum`� ece er I S 2010 Failure to do so will result in the return of your a �' .cation p c e�EALTH D��T. � ESTABLISHMENT NAME:__ �f�'I�G� �20 F�"/1lLS�S /L� TAX ID• LOCATION ADDRESS: �`cjD -- /rJ.�',v�?�i�I" �f� . 1,c/ P �1flt�'� TEL #- ;"p�"r 7�,�"�� MAILING ADDRESS: � 6S'�� ,� /�qa�l�' 'l!J/.�.p.Z673' � OWNER NAME: ��/�UL /2�Sl�l� CORPORATION NAME (IF APPLICABLE): �`��- � ,�� MANAGER'S NAME: A�3�dL 2A-��II� TEL.#: �O�-� �-7�.�� MAILING ADDRESS: 2�R 3- ti G�7` y.4�t��r, t1� /�/1 1,<7- y��}�'1��v� �yj� pZ�� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Ope3a*or{s) af�d attach a cop; �f the certif�cat�on ta�lais forr�. �. iv�i� 2. � Pool operators must list a muiimum of two employees cun ently cei�tified in basic water safety,standard First Aid and Community Cardiopulmonaiy 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 �le at your place of business. 1._ A�,� 2. 3. 4. F40D PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one fiill-time employee who is cert�ed as a Food Protection Manager, as defined in tlie State Sanitaiy Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of cei-tification 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. /f..9 /�� 2. PERSON IlV CHARGE: _ _ Each food establislunent must have at least one Person In Charge (PIC) on site duruig liours of operation. 1. ,�(� �- 2. HEIMLICH CERTffICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Hennlich Maneuver on the premises at all tuiies. Please list your employees trained in anti-chokmg procedures below aud attach copies of employee certificatious to this foi�ni. The Health Department will not use past years' records. You must provide ne`v copies and maintain a fite at vour place of business. 1. ,(��- 2. � 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER1vIIT# LICENSE REQUIlZED FEE PERl�1IT# _B&B S55 _CABIN S55 _:��OTEL S» ._INN S55 _CAMP S�5 _ S�4'I,�IMIl�tG POOL S80ea. _LODGE S55 �TRAILERPARK S10� �t4HIRLPOOL S80ea.� Y�� FOOD SER�'ICE: : LICENSE REQUIRED FEE PERl�1IT� LICENSE REQUIRED FEE PER'�1IT� LICENSE REQUIRED FEE PERMIT�= _0-100 SEATS S85 _CONTINENTAL S35 _NON-PROFIT S30 ' _>100 SEATS S160 _COMMON VIC. S60 �'VHOLESALE S80 RETAII.SER�'ICE: —RESID.KI?CHEN S80 LICENSE REQUIRED FEE PERNIIT?= LICENSE REQUIRED FEE PER�vIIT.~ LICENSE REQUIRED FEE PER'�IIT*� ' <50 sq.ft. S50 >25,000 sq.ft. S?25 VENDING-FOOD S25 ' �<25,000 sq.ft. S80 ;�f�.�7,8 _FROZEN DESSERT S40 ' �TOBACCO S» �OI ., \AVIE CHA\GE: S15 ANIOUNT DUE _ $ 13�,pp "`"***PLEASE TL?Rti'OVER A�D COVIPLETE OTHER SIDE OF FOR�1***** , ADMINISTRATIOI�j. _ _ � Under Chapter 152, Section 25C, Subsection 6,the Town of Yaxmouth 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 Certiflcate.of Worker's � � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE 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 GHECK � APPR�PRIATELY IF PAID: ' YES � NO M01'�LS AND OTIiER LODGING ESTABLISHMENTS � f TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be k 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 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, sha11 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 Department to schedule the inspection three(3)days pnor 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. ' 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 obtamed 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: i 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 RESPONSIBILITY TO RETURN ! THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, 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: �� J� SIGNATURE:__,�r �� z- ' PRINT NAl��IE&TITLE:_�nc.�L_ ��l,/�� , �/b7,/�4��1Z� ��/�I�/�, 10�06!10 � • � �TTt� Ct�mmonwealth ofMassacbusetts � Deparhnent of Industria!Accidents � �arw� � 600 Washington Street, f�Floor ' Boston,Mas� 02111 ' Workers'Compensatioa insarance AfHdavit: Baildiog/Plambieg/Ekctrical Contnctors' �t i�fir��tlN• Ptease PRIIV'P kQlbh . name: �/a-�'J C�" ��)/�S' �� g� �----T- ��. ��s: ��2_-_/l��l��-��2��-� _ +' �,n� li� • ��ll� �� ,o ��Pn�# S� �7S—�� state� � i � work site Iceation fiill addness: , ❑ I am a homeowner performing all work myself. Pro'ect T ❑ I am a sole proprietor and have no one workin tn an ca � �� ❑N�C�s�bon�]Remodel � Y P�itY• ❑Building Addition [�I am an employer providing workers'compens�don for my plaxe�ss tivocking_enlhis.}ob�- �m .��: � � ILl ,S //lUG �aa�: 54f� � ��-�aJ ��/�� ,2,g' ��: ,r �'/�r Gt�is� ➢�f 1�1� D� �7� ��a �0 8 77,3` �i'�2� . �.��0. > r�L�e ��lr�1�lu�v,c-L�� d ��..o� ic�c � — 9l �7 ❑ I am a sote propnetor,geaerai coatractor,or iwmeorvner(circ%one)and have hired the conhacto�s listed below who have the following workers'compcnsation polices: 00 addre�s• citv: D�OMt!� .. . tmma.ee ca # ad�'ess: ciri: oio�e# _ _ _ _ _ _ ___ _ _ _ —_ __ __ ___ --- -:-- - - --- insm�aaee eo, � A!l�e1i adiirl�r ai�et��, � � � Faitete b xc�r+e o�vmse as reydrod�eder Seetlo�2SA s[MGL 132 eu lad b f�e�� Yd*'s'lmprl�oeat as wd aa dH peaaitla le the for�of a 3TOT WORK ORDER asd a Aee dS1U9.OS�a�da�•f a�e�p b 11,3N�0�a�d/�r �epy s[thh sta�eme't m�y be for+nMM ls tAe O�Ice e[IoveNltaWm•f t6e DIA far eevenae veriAeaW�. 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