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Home My WebLink AboutApplication and WC i ��ti.s��::i�uVLD ' • TOWN OF YARMOUTH BOARD OF HEALTH JUN 191013 ` APPLICATION FOR LICENSEtPERMIT-21F12 �`Please complete farm and attach all necessary documents by 1. HEALTH DEPT. Failvre to do so will result in the return of your application p� et. ESTABLISHIvIIIVT NAME: �' TAX ID: LOCATION ADDRESS: l04 tU�l�,�' Se VPNLIP TEL.#: �D R�G�3-C`�� MAILINGADDRESS• S4Wt� OWNER NAME• E.l i 2[� 1 / 4afMUV'Dl CORPORATION NAME(�APPLICABLE): MANAGIIt'S NAME: TEG.#: MAILING ADDRFSS: POOL CERTtFI✓�S: The pool snper ' nst be certified as a Pool Operator,�reqaired by State law.Please list the designated Pool Opera and attach a copy of the certification to this form. 1. 2. � ,. Pool operators must list a.minimum of two emplo ees currently certified in basic water safety,standard First Aid and Community C�r�irf''pulmonary Resascitation�CPR). Piease list these employees below and attach copies of employee ce�i€�ations to ttris form.The Health Deparfinent will mt use past pears'r�ords. Yon m�t pronde,aciv copies and maintain a file at yonr pl�e of bnsiness. ,,.-3' 2. 3. 4. FOOD PROTEGTION MANAGERS-CERTIFTCATIONS: All food service establishments are requined to have at least one full-dme 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 ttris application.The Heatth Departrt�nt will not nse past years'recwrds. You must provide new aopies and maintain a file at yonr establishment. i. E!i z�cL�e�-I� MCN1d,wtC1.Vl.� a. PER50N IN CHARGE: Each food establishment must have at least one Person Tn Charge(PIC�on site during hours of operation. 1.EG za�e�-�. M�I�fawia�'a 2. HEIMI.ICH CERTIFTCATIONS: All food service establishments w' seats or more must have at least one employee a�ained in the Heimlich Maneuver on the premises a es. Please list your employees trained in anti-cholung procedures below and attach copies of emplo ' cations to ttris form. The Hea1W Department will not ux past pears'records. You must provid w copies and maintain a file at yoar place of bus�ness. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �U� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT i� IdCEAISE REQUIRED FEE PERMIT#� I.ICIIVSE REQUIItED FEE PERMIT# _B&B $SS _CABIN S55 _MOTII, $55 �N $55 _CAMP S55 _SWA�tMING POOL�80ea. �ADG� $55 TRAIIFR PARK $105 _WFIIRIFOOL S80ee. FOOD SERVICE: LICIIdSE RfiQUIItED FF� PERMPf� LICEtQSE REQUIRFA FfiE PERMIT#� IaC@ISE REQUIRF.D FEE PFd2MIT#� 0-100 SEATS $85 _CONTINENfAI, $35 NON-PROFIT $30 �100 SEATS 5160 _COMMON VIC. $60 VJ[�IOI�SAIE $80 RETAII.SEBVI(:E: KRESID.KITCI�T S� LICEAiSE REQUIItED FEE PFRMIT 4 IdCFddSE REQUIRED FEE PERMIT# LICEAISE REQUIRFD FEE PIItMIT�` _<SOsq.ft. $50 �+�A�g9R. $225 _VENDING-F�OD S25 _Q5,000 sq.ft. $80 ,_FROZEN DESSERT S40 TOBAOCO S95 NAMECHANGE: SIS AMOITNPDUE = S �v _T �'s;*PLEASE TUBN OVEB AND COMPLETE OTHER SIDE OF FORM'�""�'�s r , � 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 COME'.AFI^'IDAVIT SIGNED AND ATTACHED Town of Yanuouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � ATO MOTEL5 AND OTHER LODGING ESTABLISffi►�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to tbe temporary and short term occupancy>ordinarily and customarily associated with motel and hotei 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 mare than thirty(30)days,and an aggregate of not more than ninery(90)days within any six(6)month period.Use of a guest unit as a reside�e or dwelling unit shall not be considered Uransient. Occupancy that is subject to the collection of R�m Occnpancy 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 in ted by the Health�epazmient rior toapening.Contact the Health De�artment to schedule the inspection ttuee(�ays pnor to opening.-P AS N TE:P�ple are NOT allowed to sit m the pooi 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 ceitified 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 mnst be inspected by the Health I3epartment prior to opening. Please contact the Healt6 Department to schedule the inspection three(3)days prior to opening. CATERING POLICY: ' Anyone who caters wittrin the Town of Yarmouth must notify the Yatmouth Health Department by fll'mg the required Temporary Food 5ervice Application form 72 hours prior to the catered event. These forms can be obtazned at the Health Department,or from the Town's website at www.varmouth.ma.us under Healfh Ilepartrr►ent, Downloadable Forms. FROZEN DESSERTS: Fmzen 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress secvice),must lreve prior approval from the Boatd of Health. OUTDOOR COORING: Outdoor cooking,preparadon,ar display of any food product by a retail or food service establish�nt is prohbited. NOTICE:Permits run annually from January 1 to December 31.Tf IS YOUR RESPONSIBILITY TO RETiJRN THE COMPI.ET'ED RENEWAL APPLICATION(S)AND REQUIRED FEE{S)BY DECEMBER 15,2011. ALL RENOVATIONS TO ANY FOOD ESTABLISI•Il4IIIVT, MOTEL OR POOL(i.e., PAIlVTING, NEW EQUIPM��IT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMbiENCEbiIIVT. RENOVATIONS MAY UIRE S LAN. DATE:� � ?j SIGNA � �� PRINT NAME&TITLE:� Rev.10J25/1)