HomeMy WebLinkAboutApplication and WC, .�
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� TOWN OF YARMOUTH BOARD OF EA,�TH -� � --e _�
� � APPLYCATION FOR LICENSE/PER���'��20�11 � � �� � "' ''� �
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1 Please com lete form and attach all necessa d�m ecem er 1�'?A�fl, �� .,� �
. Failure to do so will result in the return of your application pac et. g
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ESTABLISHMENT NAME: � µ' � C�� � . TAX ID:
LOCATION ADDRESS: TE .#:
MAILING ADDRESS: �
O�VNER NAME:
� CORPORATION NAME (IF APPLICABLE): �(�, ( t�Q
; MANAGER'S NAME: C� TEL.#: �
� MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified s a Pool erator,as required by State la�v. Please list the designated
Pool Ope�az�(s) and-att a co�y��zf e ce ' cation to this foi�nx. _ _ . __ _ -
1. 2.
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', Pool operators mu ist a i ' ' uin of two einployees cui-�ently cei�tified in basic water safety,standard First Aid a�id
Commuuity Cardi u ry Resuscitation(CPR). Please list these employees below and attach copies afemployee
certifications to this rm. he Health Department will not use past years' records. You must provide new
copies and main in a �le at 3�our place of business.
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�• 4.
' FOOD PROTECTION MANAGERS - CERTIFICATIONS: '
All food service establislunents are required to have at least one fiill-time employee who is certified as a Food
Protection Manager, as defm d 'ui the State Sa�utary Code for Food Sei �' a�slunents, 105 CMR 590.000.
i Please attach copies of certifi tion to this application. The He epartment will not use past years'records.
� You must provide new copi s and maintai �our establishment.
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PERSON IN C E:
_ -- - _ �__
Eacli food esfab unent musf 1 ve at least one Persoii Iii Charge (PIC) on site duruig liours of operation.
1. 2.
HEIMLICH CERTIFICATIO S:
All food service estaYzlishment with 25 seats or m • ave at least one employee trained in the Heunlich
Maneuver on the premises at a 'times ase ist your employees trauied in anti-chokuig procedures below and
attach copies of einployee cer ' catioi o this form. The Health Department will not use past years' records.
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You must ro e n w co 'es nd maintain a �le at o r 1
P y u p ace of business.
1. 2.
3. 4
RESTAURANT SEATING: TOTAL #
OFFICE USE O1V'LY
LODGI\G:
LICENSE REQUIRED FEE PERtV1IT� LICENSE REQUIRED FEE PER\�IT� LICENSE REQUIRED FEE PEIL'VIIT#
_B&B S�5 _CABIN S» �10TEL S»
_INN S55 CAi�IP ���_ �SIk"L�l�'IiNG Pn(�L SRnea
_LODGE S» `TRAII,ERPARK S10� ���HIRLPOOL SROea.
FOOD SER�'ICE:
LICENSE REQUIRED FEE PER�VIIT� LICENSE REQUIRED FEE PER�fIT= LICENSE REQUIRED FEE PER'�IIT�=
_0-100 SEATS S85 _CONTINENrAL S3� NON-PROFIT S30
_>100 SEATS 5160 _COMi�fON VIC. S60 �'�T�OLESALE S80
RETAII.SERVICE: _ —RESID.KITCHEN S80 _
LICENSE REQUIRED FEE PERbIIT� LICENSE REQUIRED FEE PER..��IIT� LICENSE�EQLIIRED FEE' PER'�IIT�
.,_ .. ..
<SO sq.ft. S50 >25>OOO sq.tt. S2?5 ' VENDING-FOOD S?5 .
— 2Q — _
I <2�,000sq.t�. S30 �I�07✓ _FROZENDESSERT S40 I TOBACCO S» .��(�p,Z(p
����E CHr1\GE: sis AM4UNT DUE - $ L3�..�pZ�
**R*�PLEASE Tti'R\O�'ER A\D CO�TPLETE OTHER SIDE OF FORJI"****
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ADMINISTRATION
Under Chapter 152, Section 25C;'Si�bsection 6,the Town of Yarmouth is now required to hold�is�Zance o�renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Work�-'s '
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED�ND SIGNED, OR
CERT. OF INSURANCE ATTAGHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHE
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK '
APPROPRIATELY IF PAID:
YES NO
1VIOTELS AND O'THER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall 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 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 I
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 thre�(3)days
pnor to openmg.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WATER TEST`ING: 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. �
POOi.CLOSINCG: 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.yarmouth.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 RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
AL,L RENOVATIO�T T ANY EOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i:e., PAINTING, NF�JV
EQUIl'1VIEN , TC.), � ST REPOR APPROVED BY THE:BOARD OF HEALTH PRIOR
TO CO1VIlV1E ME T. R N VATIO MAY RE S TE PLAN. ` ��
AATE: SIGNATURE: C�%N �
INT NAME&TITLE: f��J� �t��l `� �"
10�06'10
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11/16/10
Association Benefits Ins Agcy inc
210 Broadway,Unit 201
Lynnfield,MA 01940-1121
MA Retail Merr.hants WC Group Inc.
Cape Wine 8�Liqupr,Inc. '
443 Stati�Ave
South Yarmouth,MA 02664
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NO 014005030752111 1J01/11_ 1/01/12_ i
_ _ 100,000
500.000
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Town of Yarmouth
ATTN:Licensing Office 35 !
1146 Route 28 I,
South Yarmouth,MA 02664