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Home My WebLink AboutApplication and WC � ..._�..,___� _�_ � � TOWN OF YARMOUTH BOARD OF HE ��' � �;� . , � � APPLICATION FOR LICENSE/PE 2 " s: : n;. r .r.,• ��• �. " � � �:,_ _ � �. . ,�. * Please complete form and attach all necess uments by Dece ber IS 20I1 � Failure to do so will result in the return o 'your application p � e�:ry� ` g =, � . .. ,,..»..... ._,......�,m.,�N.....�-.9 . ESTABLISHMENT NAME: �� 5 1 � h� �� • 2 LOCATION ADDRESS: p� I n5 �n C� TEL.#: �' 0 '� 3^7"3�i�.l MAILING ADDRESS: vi � 0 d I�Ymb�l � � OWNER NAME: I�( Yl-{" i'D G� �,r Sa� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor�nust 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. L 2. Pool operators must list a minimum of two employees c y certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitatio . Please list these employees below and attach copies of employee certifications to this form. T ealth Department will not use past years' records. You must provide new copies and main ' de at your place 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. 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. l. 2. 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�le at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# � _B&B $55 _CABIN $55 _MOTEL $55 � _INN $55 _CAMP $55 _SWIMMING POOL $80ea , _LODGE $55 _TRAII.ER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 , _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: �LRESID.KITCHEN $80 ,:�r�'f / LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ ��- � *****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 of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. 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 t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES �--�� NO MOTELS AND OTHER LODGING ESTABLIS�IlVIENTS 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 Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOL5 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 prior to opening.PLEASE NOTE:People are NOT allowed to sit in 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 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 prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, i Downloadable Forms. � r 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 of Health. � OUTDOOR COOKING: , Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. , • P SIBILITY TO RETURN ' NOTICE.Permits run annually from January 1 to December 31. IT IS YOUR RES ON THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. A.LL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � f SIGNATURE: PRINT NAME &TITLE: � �( � �'�� "\ Rev.10/25/11 ' � The Cnmmonwealth of Massachusetxs � Department of Industrial Accidents N�C�M�Mli 600 Washington Street, 7`�'Floor , . Boston,Mas� 021I1 • Worlcers'Compeasation Iasarance Aftidavih �i�a�adn: Pka�se PRINT feeibh �: L 0. C 1 �G.� �.�'1 (�1�5 01� ad�s_�_�U 1 I�j r _S_bY�G� �G�------ ciri 1 Ll�"m UU��"1 d 6�'�'" state: m�`_' zio• O � 7 5 p�# ��3$�2 �7� 3 �s3 wrork site Iocation fiill address: `� � U �h �(� � A r m G � �h ��' �l( D�� ' I am a homeowner perfom�ing all work myself. �Y3m a sole proprietor ac�d have no one working in any capacity. ❑ I am an employer providing workecs'compensati�f�my employees worlcing on Wis job. comaaav me: address: citv: Mwae N: Ins��ee ca _poHc�N ❑ I am a sole proprietor,ge�eral co�tnctor,or 6omeowwer(cucle oni)and have lurad the conhactors listed below�who�have the following workers'compen4ation polices: comoaov�e- address- citY• p`oae J!- les�a�ee ca pd(�� coaw�v�me• a�ras• c�': oYo�e M- imva�ee oo. ��ev g Allrelt M�Y i�t�rrerr� Fafle+e 0�sa�re or�aa�e as reqsired��dv 3�e1iw�ZSA�[MGL 1S2 ea�Ind b IYe hrp��teri�id pn�itln�f a Au�b f1,SM.M aid/Mr o�yean°impr�.�c�.wa as dv��e ue hr..ra s�ror wo�cx oRnER..a.e.e.rsie�.w.aay�aro,c de. t e.aasd.a�a �.pr.r w.�.�..r n�r.�,...�a��oee�.r i.�n..�or er�uu��..��u... /Jo Arer+tby cer�ffy xader Nie �w.r ewl pewaltiea of perjray tArtt tlie lwfonw�tlon prevl�le�aboae is due rtwd oe�rert SiB�� Date _ G� V`ul t c� Print name � r D� '� l/�V � G � S 6� Phone# ��4�' � J � ��J efBcW ex oNy de net write d t6b arn to be rn�Pleted 6Y ei�'or l�wn a�l eity or tewn: permiNNeeme# �Bnidies Departiment ❑edeek if Immediale reapeme b rcqaired a�� Sdectse�s Of�ce ��i� phNe#' �� t