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Home My WebLink AboutApplication and WC , �� TOWN OF YARMOUTH BOARD OF HEALTH � �q��(��VJ[� � � APPLICATION FOR LICENSE/PERN��,.,2� `��` ...,. � �J �, �,�., � v L J i 1 * Please complete form and attach all necessary do�ume�f�y D �9n ' S ��11. Failure to do so will result in the return of y€�ap�tion pac t. HEALTH DEPT. ESTABLISHMENT NAME: �� MC�C �JI ID: LOCATION ADDRESS: c.�}�- � � f%Y�c,�, �EL.#: — � MAILING ADDRESS: ne . OWNER NAME: ' CORPORATION NAME(IF APPLICABLE): �/S armacy, nc. MANAGER'S NAME: Q�' , D�1 __ _ TEL.#: �(�'=7'�1�y� ' MAII.ING ADDRESS: '�`.� �i�..v�c.�J1.. j'1(�A POOL CERTIFICATIONS: The pool supervisor 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. ! 1. 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 fil�at your�l�e of business._ __ __._ _ : � � l. 2. ' 3. 4. FOOD PROTECTION MANAGERS - 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 Food Service Establishments, 105 CMR 590.000. i 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 file at your establishment. ' i 1. 2, i PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 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. 2. i 3. 4. i i _- ___ _F.ES'�'��TK.AI�IT SEA.T-ING: TOT.��,#� __ _ _ _ _ . _--_--- -----_____ I -- ---_ - f OFFICE USE ONLY ; LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _B&B $55 _CABIN $55 MOTEL $55 � — � _INN $55 _CAMP $55 _SWIMMING POOL $80ea. � _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. I 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 RETAII.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 : 2�,( i I <25,000 sq.ft. $80 �� —FROZEN DESSERT $40 �TOBACCO $95 �a�d✓ ( j NAME CHANGE: $15 AMOUNT DUE _ � I 1 S.QCl � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****�' ' � � � , , ADMINISTRATION �� Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal I of any license or permit to operate a business if a person or company does not have a Certi�cate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ,, . OR I 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 CHECK I APPROPRIATELY IF PAID: ' YES NO ' MOTELS AND OTHER LODGING ESTABLIS��VVIENTS 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 e?s��vhere.Tr�sient necunar:cy shall ger�rally refer t�c�ntinuo�s aecupar�cy nf not m�re than thirty(30)d�ys,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. FOOD SERVICE SEASONAL FOOD SERVICE OPE1vING: 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 priorLLto 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 certif'ied 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 of Health. 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIlZED FEE(S)BY DECEMBER 15, 2011. AT.i" RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY � QUIRE A SITE P , ___ .__ DATE: g �� SIGNATURE: PRINT NAME&TITLE: �oanne P. Amitrano smg oo nator Rev.10/25/ll �`•,� T"�ep �orntnornye�lt� of IV�nssacKusetts �� 3eparttnen£of�niiustrial z4icciuents r- ��° i��!?i��Sr:a YLfLOtl� � �t�� YCSj3Tlt�Ott i�17 E� `" �`tJSZOT�� i� ��',��:� ,�- Wi�Vlt�.tltllSS.b OVfQltt 't�►%orl�er�' �vrnpen�atic�n�n�uran��Affrr�a�!i�: �neral:�usinesses _ A�nii�ant�nformafiion Ple�csp��int�..e¢ib��, . 'r'� '__ Y:'l��a? .:�i..� h.... ...� ni7t` /�.1. .... L'. �- )��. .. . ... . .. .. .... . . . .. . .. �... . . �1"411�1/Yf+.aur +�.n+ . .� v lv. •• . ••j a Ti ✓ l� �,��: �S '��- a� � c��-y�,��, � ��-�� ya� �itylStateJZip: t� �'hane,�: � tsre you an�mpiover?Check'the apgropriate b�za � I B�rsiness'�'�e(��c�nir�ctl= 1 I.L� i am a�mptover witn empiovees(�uli an�J ' =- c`n--�' �V.�`i j orparE,time�.* 5. �i�ecr�,r�„vssrl".r,�,n�'Establishment 1 ?.❑ i am a.sple pr�pnettir�r pannership�►d have no ?. (� d�ice and/or 5a�s(incl.real estate,auto.et:,.j � emgToyees worlfl.n�for me in a�capacit�-: ' [I3o�vvo�it.eis' �caaro.;nc„rance ret�uire�] �. �I�I�an-profit � �.❑ �IJe are a�ar�c�ra�on�►d�ts�ff'icezs have exercised 9. ❑ Entertainment I i �heirri,�ht c�f exempnon�r c. t52, §1(4),a��e have 1C1.��?fanu:a:,^Lurin� � no�mpl�y�es,ft3o�vorkers'c,Qmp. insutance rec�uired]* 2I:�Keaith Car: I 4.❑ fii%e ar�a no�-pzaf�t orgdniau4n staffed'a�-valunteer�. ' �._. ' � � withna�mplati�es.[I;ia:wor�ers' �omp.insu.-an„^ereq.) E I Z='.❑ C3tner ' *riny appticant that checks boa#1 must al�o fill nut the sect,ion t�eiow suowing ttaeir workers'compensaiion pol�cq information. *�If the corporace officets.ksave exempted#hemselvas,but the coxposation has oTher emplc�,yees,a workers-ccjmpensation poli�y is zec}uire3 and such an ozsanizatinn snouid check i�oa#1. I um�n>errzpf.r►ver thutis pr�vi,r�ne avanfcers'compensmion insurunce�or�'e»sP14!vees. �ei,uw is�lic po�i�,y znl�+rm�aior� Inci,ran��Dmpa�.t��Ivarue: Ivey1 Hampsnir� Zr.:suranaG Compar.�' Insut�r's Ad�lre5s: 1:',� Lda~a r 5*r�e~ �iivl�tat�IZip: N�y' Yori�. Iv:' 1003� Pnlic3-#:ar�e3f-ins. Lic:� 43�9 3 n? E�ir,atinnDa�e� 01 101/2 p 1'' �ttacf�a�agy of the war�ers'com�ensu�icsn:notic��r�ec#acafi�on pu�e{�ho�vin��th��rc�iicy number ant!eauira�i��ciuc�l, ' ��lu,�tu�e�e cavera�e��Qu�ired�sut,:r.��crion��or i'vt`��,.c. i�::�aniLa�to i��irmsasitian of cn��n�i��alties flf� z"uze�up to�1.��3�}.pU and/pr oar�=year iznt�r�scsnment as�vell.as:cisril�nalties in t�:,f�rm of:��TOP i�VORZi fJJRI)r�'.ana�fir� c�f up ta.��S�.O�J.a riay agains:�e vioiataa. Be adazs�d that a co�- of ti�s�ta.te�ern ma3�be zarwarcied to t�Ofriee oi }:mresagauons�f#he I3IA f4r insurance coverage verificauan #�n�r�tiy .'.fy, emder#h .p ` p�rua�s of per�ury tha�the infvrmul�nn pravirfed crbove.is�rue.un�carre�. .. _ � a ��-�� ,ar� �3�e� ��1��: �; 7oanne P. Amitrar�- _ f � (lffteuxl use nnft•. Z3o nvt write in t�iis nre�, to be cvmpl�ed i3v.�iiu or unvn��"ieial. i � i 1 �if'Y,OT'�OWII: _��h'T411�.�iC�ItS�f i '; u . - . . . .. � � :, Issuizer Authari�y r�circie one,; li I. Board o€�ealth �. Bu�idin�3�enartnae�t s. Cityl�ow� �fer� �. �icensiat�Baard �.SLlecrme�.'s��i;e i; �. �?ther � �� ,'� : I � � �ontact?erso�: P�one�. � � �vww.mass:6avi ai:: I f 1