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Home My WebLink AboutApplication and WC �� l ' TOWN OF YARMOUTH BOARD OF HE � �" �� ' '�` � �� } . � APPLICATION FOR LICENSE/PE ,�,�, p„� `V; , � �. ,� �5�". � L 4,;,' * Please complete form and attach all necess��4 ' t y� Failure to do so will result in the ret'i�t�'� y ° �pplicatio T. ESTABLISHMENT NAME�� CQ.P c� PQ r N r TAX ID: LOCATION ADDRESS:___ 't�6 M,�� ,� St,ze e T W eSr Vi1�Ma�h TEL.#: 50�-��S��l�a v MAILING ADDRESS: OWNER NAME: �o c�-s�et� fyo t�� n�P CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 'z'�� 5,�,,,�� L TEL.#: .Sa& ,�6�. _g-?,Z 6 MAILING ADDRESS: to� �'.t.�ea� s�. ,t ��n�P S �v� C'e N fiP�2aJ l61�e �,T, n�.,63 Z- POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Poot OperRtor,as required by State law. Please list the designated Pool Operatox�s) aiid attach a c�y_of tlie_c�a-ti�cation to this form. _ 1- �'�".�(>.�i✓ f'J�!s'��`� 2. Pool operators must list a minimum of two employees currently cei�tified in basic water safety,standard First Aid and Community Cardiopulmonaly Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this forni. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. �,t-i s/''�v N Z��7" /S Is,��` 3. � �o�. Z 4, - FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establislunents aze required to have at least one fiill-tinle employee who is certified as a Food Protection Manager, as defined 'ui the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to tlus application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. �/JV rt�.�'l /) /�,� � 2. PERSON IN CHARGE: Each food establislunent must liave at Ieast one Person In Charge (YIC) on site duruig liours of'operation. / 1. �?�N�"i lSs�� 2. HFIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your employees trauied 'ui anti-chokuig procedures below and attach copies of employee certifications to this foiYn. The Health Department will not use past years' records. You must provide ne�v copies and maintain a �le at your place of business. / 1.�!��T � l y�� 2. 3. 4. RESTAURANT SEATING: TOTAL # `7� OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERMII# LICENSE REQUIRED FEE PERiifIIT?� LICENSE REQUIltED FEE PERiVIIT� _B&B S55 _CABIN S55 ��40TEL S» �1 �.. p ----- mi�l-�k1L ut� �Q�I� _INN S55 _CAMP S» 3 S��7INGPOOL S80ea. _LODGE S5� �TRAILERPARK S105 I �4'HIRLpOOL S80ea. �r�"�� FOOD SERVICE: LICENSE REQL'IRED FEE PERMII'� LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERVIIT# I 0-100 SEATS S85 �(I-031 _CONTINENTAL S3� _NON-PROFIT S30 _>100 SEATS S160 �CO'�IMON VIC. S60 —�LS `VHOLESALE S80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�IIT?= LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PER'�IIT# _<50 sq.ft. S50 _>25,000 sq.ft. 5225 VENDING-FOOD S?5 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S55 ��`zE c��cE: sis AMOUNT DUE _ $ 520��O '"****PLEASE TtiR\OVER A\D CO�iPLEI'E OTHER SIDE OF FOR�7�*"** �:: � 'y < • ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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. T'HE 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 issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: � YES. NO � . M�'��g.�At�7�"i a'��.R I.�.i�DGu�i��'ABi.ISiHM�NTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy sha.0 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 three(3)days ' pnor to opening.PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. E I 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. �` - I��t)i.�I.�l►S�T�: �very outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE SEASONAL FOOD 5ERVICE 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: f 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 obtauied 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. i - _ _ _ - -- 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 7anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN TI�COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL N. � DATE: `��'�� SIGNATURE: � � PRINT NAME&TITLE: � 10 06'10 � _ �-_ ._ _ i � . 3 i � Title: Schedule of Locations Remazks: Cape Point Hotel 476 Main Street W. Yarmouth, MA 02673 Cape Town & Country Motor Lodge 452 Main Street W. Yarmouth, MA 02673 Mariner Motor Lodge Inc 573 Main Street Route 28 W Yarmouth, MA 02673 / This endorsement is attached to the policy Indicated beiow and is effective on the date stated hwein,at t2:01 A.M.,slandard time at the address of the insured as described In the informatbn page. Policy No. Group Expiration Date of Policy Effective Date of Endorsement Endorsement No. WMZ 8005077012010 0500 04/O1/2011 04/O1/2010 Issued to Additional Premium Retum Premium Dockside Hotel Group,Inc.Etal ISSUED BY: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY Countersigned �\�..� Authorized Representative -