HomeMy WebLinkAboutApplication and WC � ` .__y:,.
TOWN OF YARMOUTS BOAR1�..�4���,i��.. 9T��, t T �V* �[��(��D
APPLICATION FQR LTCENSE/P��i�'�''=ZOl �
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* Please complete form and attach all necessary t�ocuments, y D�ecem er IS"2��.._��.
F a i lure to do so wi ll resu l t in t he r e t urn a f yaur app lica tion pac e t�-�E A L I H u t r i.
9
NAME OF ESTABLISHMENT: C J�AG5 ����cs-��,,�. TEL. # Sn�-77.�r'-��
LOCATION ADDRESS: �'4d� lYl.�tiU ,�T�I.Q�fs �St�/.¢-.ted�llz��-0�,�73
MAILING ADDRESS: .�.�isi�,�� �y�
OWNER NAME: , 1�vL �-�,�-rti TAX ID (FEIN or SSN,�
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CORPORA.TION NAME (IF APPLICABLE): � � �
MANAGER'S NAME: L � TEL. # Sr9S-77S'- dQ�
MAILING ADDRESS: � �"
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 certificarion to this form.
1. __ _ �� 2. T�� _
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Comtnunity Cazdiapulmonary Resuscitation(CPR). Please list these employees b�low 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 fUe at your place of business.
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3. ..�a� 4. ..�l�
FOOD PROTECTION�vIANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least ane full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Pood Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health DepRrtment will not use pAst years'records.
You must provide new copies and maintain a file at your establishment.
1. . . s��iE- 2. �[9��
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PERSON IN CHARGE: _ __
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Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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HEIMLI.CH CERTIFICATI�NS:
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 tirnes. Please list your erYployees trained in anti-choking procedwres below and
attach copies of employee certifications to this form. The Health Department will nat use past years' records.
You must provide'new copies and maintain a fiie�t your place of business.
1. ��t, 2.
3. _ �,� 4 . f� �
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RESTAURANT SEATING: TOTAL#
OFF'�CE USE ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUTItED FEE PERMIT#
_BBcB $55 _,_,_CABIN $55 _,,,MOTEL $55
�INN $55 �CAMP �55 �SWIMMING POOL $80en.
�LODGE $55 ,_,_TRAIL.ERPARK $105 __,_WI3IRLPOOL $80ea.
FOOD SERVICE:
LICBNS�REQUIRED FEE P$RMIT# LICENSE REQUIRED �EE PERMIT# LIC�NSE REQUIRED FEE PERMIT#
„�0-100 S�ATS $85 _CONTINENTAL $35 �NON-PROFIT $30
>100 5EAT5 �160 �COMMON VTC. $60 �WHOLESALE $80
RETAII.SERVICE: --RESID.KI1"CHEN �80
LICEN$E lt$QUIRED FEE PERMIT# . . LICENSE REQUIRED FEE PERMIT# LIC�NSE REQIJIRED FEE PERMIT#
_„<50 sq.8. �50 >25,000 sq.ft. �225 �VENDING-FOOD $25
„�<25,000 sq.ft. $80 10-02 _FRQZEN DESSERT $40 I TOBACCO $55 0—O
NAME CAANGE: $ts AMOUNT DUE = $ 13 5•o0
"'""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"**
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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 pernut to operate a business if a person or company does not have a Certifica.te of Worker's '
Compensation Insurance. THE ATTACHED STA'TE WURKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR _ - f
E
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CERT. OF INSU.R.ANGE ATTACHED t/ _ ,
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your penmits. PLEASE CHECK
APPROPRIATELY IF PAID: �
YES � NO �
__ _ _ _--- - _ -- _ M9���S-�ll�€�4�5E-1t Lf3I�INF ES'£�A���.ISHMEA�'�� _
TRANSIENT OCCUPANCY: For purposes of the limitations pf Motei or Hotel use,Transient occupancy s1�all be �
limited to the tetnporary and short term occupancy, ord�narily and customarily associated with motel and hotel use. i
Transient occupants must have and be able to demonstrate tha.t they maantain a principal place ofresidence�elsewhere. j
Transient occupancy sha11 generally ref�r to continuous occupancy af not more than thirty (30) days, and an ;
ag,gregate 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, a.s defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
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POOLS
POOL OPENING:All swimming,wading and whirIpools which have been closed for the season must be insp�cted
by the Health Department�prior to opening. Contact the Health Departme�t to schedule the inspecbion three( )3 days
pnor to operung.PLEASE NOTE:People aze NOT allowed ta srt in the pool area until the pool has been inspected ;
and opened. �
POOL WATER TESTIl�TG: 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 CLOSYNG: Every outdoor in ground swimmin�pool must be drained or covered within seven(7)d�ys of
clasing.
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FUOD SERVICE �
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CATERING POLICY: ;
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmart 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.
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 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/waitxess servic�),must have prior approval from the Board ofHeaith.
OUTDOOR COOI�NG: '
4utdoo�coo_ 'n re aration,or dis la�of an�y food product by a_r_etail or food serv_ice establishment isprahibited.
NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.I1'Y TO RETURN
TI�COMPLETED RENEWAL APPLICATIpN(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENC)VATIONS TO ANY FDOD ESTABLISHMFNT, MOTEL OR POO�. (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN.
DATE: 11 ? l/ p � SIGNATURE:
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PRINT NAME&TITLE: l�',�,j�,/2�.- �UZ/�-.S Zd-'l n �- I�.�',U/�'i6„�rt9�
09/25/09
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� The Commonwealth o Massachusetts
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Department of Indushzat Accidents
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600 Washington Street, 7`h Floor
� Boston,Mass. 02I11
� 'Worlcers'Compensallot ias�rance A�davir Baitdiog/Plambing/Eleclrical Contractors
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, ❑ I am a homeowner performing all work myself. Project Type: ❑New Co�nst�tion QRemodel
❑ I am a sole proprietor and have no one working in any ca�city. ❑Building Addition
(� I am an employer providing wo;ke�'compensation for my empioyees wodcing on this job.
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