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Home My WebLink AboutApplication and WC, _� � � ��G�sv-rws Til,+�� K/Y TOWN OF YARMOUTH BOARD OF HEAI�� , � � AP`PL�CATION FUR LTCENSE/PE �� ;: , ° � �,.: ��`�� _� � � * Please complete form and atta.ch all necessary documents by Decemb � 1 S 2009. � Fail.ure to do so will result in the return of your applicatton pac " . �� ' ��s�� NAME OF ESTA$LISHMENT:_ Christmas Tree Shops, znc. TEL�- ={ " LOCATIONADDRESS:_511-525 Main Street, Rt. 28, West Yarmouth, MA 02673 MAILING ADDRESS: 64 Leona Drive, Middleboro, ,MA 02346 ' OWNER NAME:__ Charles G. Bilezikian T� ID (FEIN or SSN�' � CORPORATION NAME (IF APPLICABLE): Christmas Tree Shops, Inc. ; MANAGER'S NAME: Mark Guiliano TEL. # 508-775-8151 � MAILING ADDRESS: same_�� above l 1 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. ___ 1. 2. �' Pool operators must list a minimwm of two emp loyees currently certified in basic water safety,standard First Aid and Conatnunity Cazdiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificarions to this form. The Health Department will not use past years' recards. You must provide new copies and maintain a file at your place of business. i �. a. 3. 4. FOOD PRdTECTION 1VIANAGERS - CERTIFICATIONS: All food service establishments 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 Faod Service Establishments, 105 CMR 590.000. � Please attach copies of certificarion to this application. The Health Department will not use pRst years'records. i You must pravide new copies and maintain a fde at your establishment. ; 1. 2. ; � PERSON IN CHARGE: �ac-h tood establishmenf musf.have at least one Person In��iarge (PIC) on site dwYn�hours a�nperation. . 1. 2. HETMLICH CERTIFICATIONS: All foad service establishments with 2S seats or more must have at least one em lo ee trained in the Heimlich P Y, Maneuver on the remises at.all rime . Please list our lo ee trained in anti-ch r c d s e w p s y emp y s okmg p o e ure b lo and attach copies of employee certifications to this form. The Health Department will not use past years' records. Yo.u.must pravide new copies and maintain � file at your place of bnsiness. ' 1. _ 2. - 3. . :4. RESTAURA.NT SEA'I"ING: TOTAL# OFFICE USE ONLY LODGING: LIC�I�TSE REQLTTRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENS�REQUIRED FEE PERMIT# ,�B&B $55 �CABIN $55 �MOTEL $55 �1NN $55 �Ct3MP $55 _,_,SWIMMING POOL �80ea. �LODGE $55 �'TRAIi..ERPARK $105 _ ,_WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUlRED FEE P$RMIT# LICEI�TSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# __,_0-100 SEATS $85 �CONTINENTAI, $35 �NON-�ROFTT $30 >100 S$ATS $160 _„_COMMON VIC. $60 �WHOLESAL� $80 RETAIL SERVICE: �TtESID.KITCHEN $80 LICENSE REQUIRED FEE _1'ERM1T# LICENSE REQUIRED FEE PERMIT# -- -LIC£NSE REQUIRED FEE PERMIF# �<50 sq.R. �50 >25,000 sq.ft. $225 ,_VENDING-FOOD $25 ��S,OOU sq.8. $80- ,��,� ..�FROZ�N DESSERT $40 �TOBACCO �55 �y�______ Na�n�cxart�E: $is AMOUNT DUE = S So 0 Q. '**""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF�ORM*�"� ,`: .�� --____- . � ,�--,-:�. � } 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 pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insura�ce. 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 iasuance of your permits. PLEASE CHECK � .APPROPRIATELY IF PAID: ' YES NO -_ _ MOTELS AND OTHER LODGING�STABLISHMENTS � Tl2ANSlENT OCCUPANCY: For purposes of the limitations af MoteI or Hotel use,Transient occupancy shall be � limited to the temporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use. � Transient occupants must have and be able to demonstrate thax they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of nat 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, shaU generally be considered Transieut. i _ __ _ E � POOLS _ I E POOL OPENING:All swimming,wading and whirlpools which ha.ve been closed for the season must be f by the Health Department priar to opening. Contact the Health De�artmetrt to schedule the inspection t�nree( )days pnor to opening.PLEASE NOT]E: People are NOT allowed to sit m the poal area until the pool has been inspect�l and opened. POOL WA7'ER TES7'ING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) d�ys prior to openin�, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or cove�ed within seven{7)d�ys of k closittg. FOOD SERVICE j I CATERING PULICY: , � Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the reqwred � 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. € f OUTSIDE CAFES: � Outside cafes(i.e.,outdoor sea.ting with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: ' _____Outdoor.caokin�,t�ret�aration,or di�la�of any food product by a reta.il or food serv�ice establishnnetrt is proltibited.__ j ; � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIII'Y TO RETURN THE COMPLETED RENEWAL APFLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ; ; ALL RENOVATIONS TO ANY FOUD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY 1'HE BOARD OF HEALTH PRIOR ; TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' � � DATE: 11/24/09 SIGNATURE: ��-� �.� � � PRINT NAME&TITLE: Carol oldham, Secretary ; � � 09125/09 � , M^' ' t� � Tl�e Commanwealth of Massachuselts Department of Industria!Accidents �� 600 Washit�gton Stree� 7`�'Floor Boston,Mass. 02111 Workers'Compeasatioe iesara�ee Atfidxv#:Bai'Iding/Plembieg/Electrical Contractors �it,��tie�ts P'lea_�PRQVT k�i�tv ` � name_ address: c� state� zio- phone# � urork site locati�(fWl addressl_ ❑ I am a homeowner perfornung all work myseif. Projeet Type: ❑New Construction ORemodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensati�for my�apbyees wodcing on this job. comu�v eame: - Christmas �ree Sh�s� ��c� : _ . _ - _ . aadreas: 529 Route 28 - citv- West Yarmouth, MA D2673 ��#- '508-775-8151 ' � e Com an 11WC14956602 �:__ ... �::;�- _: ;:• r •s._,:. �,_.>._;.,�- ,�;n:�, ,�f -�� •.��*��. ' �.::�: Q I am a sole praprie.�or,g�eral coetracter,or homeowwer(cirde owe)and have luc+ed the co�ractacs lisced below who have the following workers'compensation polices: ooinwav�a�c: addresa: citw. ' �hoae#- � . _:r.,�,:-� � . , �': �.��'�"�'�' ��:� oosma�f ine: addr+cn: � ,�Y; ' � nkoae�- � . _ _ ___ _ __ --------. . , ... . , .,: .. _ ' 'Failiu+c b set�re n > � _. . ,. :r:�,� �..�: .�:�,�"� �..�;.-n3��:-,�`f�'�-�� _-•k '�'��_�� ." , _.;' � �9�'��+See1i�2SA�f MGL IS2 ae kad t�Ike irp�t�feri�ial�na16a�f a�e�N;I,SM.N aa�Ver �Yp*s'�t aa wr8 as dH pea�qa�tie��f a 3TOT WORIC ORDER aaA a Me e[S1AaM a dap apl�t re.1 aderriaad tdt a � a�@��f 1i�dai�t mr be foe+►ndai M tYe Omoe�laratlptl�ns�f IYe D1A ta�ara�e v�atlN. L lo Are�by cerBfy ruder Nie peias�pe�ofPerjx�'tA�at d�e�fornte[lea pno►+ided obone ts Ar4te�wd� Signatuoe �� _ � 11/2 4/0 9 pr;�� Carol Oldham� P��# 774-213��i000 �ffieial ae oaly do�t write i this arn to ie Qs�ple�bY.cky K Mwa��eiai . dly or t�wo: ;_�� .�� ❑ekeat if i�me�a�e n�psme b itqwired , �y O�loe � pi��e�F; ��t P�� c�a sm�iaa+� ,-� .;,�,