The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � � � � �� , p OWN OF YARMOUTH BOARD_OF HEALT� u.t �w� F � . '• c g . '-- ._ . . . — �o APPLICATION FOR LICENSE/PEFt�1�' 11� ' �ia�� ZO1� 4 � F• ! � rk.:' �� il * Please complete form and attach a11 necessary d ��ii�ie ,�� ,ember 5 2010 Failure to do so will result in the return of�tzr a plication packet. � N:�� . ,_: :-_��. ESTABLISHMENT NAME: t� �°�� 1� ��I'�-Q TAX ID: � LOCATION ADDRESS: 93 1`�c��v� s TEL.#: ��' -3 � -��'� MAILING ADDRESS: io �� S C'" � �..,��" u�. f`�1 Pt pt$D3. OWNER NAME: o�ti." •�•5 4 CORPORATION NAME ( �'LICABLE): �'c��r kar Np�� c� �'�.q L+-G MANAGER'S NAME: Sa�vy1°`� o� ►'I�P /�a r�S�v�-- TEL.#: ��& - 39� -�.�� MAILING ADDRESS: I D,S� �L�j�i wjt M S� � �U✓ ��e � r�A O j�t�� POOL CERTffICATIONS: 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 forni. 1. 2. Pool operators must list a minimum of two employees cun ently certified'ui basic water safety,standard Fu st Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee cei�tifications to tlus form. The Health Department �vill not use past years' records. You must provide new copies and maintain a �le at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is cei�tified as a Food Protection Manager, as defined 'ui the State Sa.iutary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to tlus application. The Health Department will not use past yeRrs' records. You must provide new copies and maintain a tile at your establishment. L 2, PERSON IN CHARGE: Each food establislunent 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 'ui the Heimlich Maneuver on the premises at all times. Please list your employees trauled in anti-chokuig procedures below and attach copies of employee certifications to tlus 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 LODGI\G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PER��IT# LICENSE REQUIRED FEE PER�YIIT# _B&B S�5 _CABIN S5� LYIOTEL S5� �U-oss _INN S55 _CE1MP S55 �SWLVI;VIING POOL S80ea. �/(—Q� _LODGE S» �"TREIILER PE1RK S 105 ��IIRLpOOL S80ea. FOOD SER�'ICE: LICENSE REQLTIRED FEE PERMIT.= LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER�'�1IT� _0-100 SEATS S8� �CONTINENTAL S35 I�-� _NON-PROFIT S30 _>100 SEATS S160 _CO'��IMON VIC. S60 ��IOLESALE S80 REI':UL SERVICE: —RESID.HITCHEN S80 LICENSE REQUIRED FEE PER'�IIr� LICENSE REQUIRED FEE PERVIIT.~ LICENSE REQUIRED FEE PER\1IT# _<50 sq.ft. S50 _>25,000 sq.ft. S?25 VENDING-FOOD S25 _<25,000 sq.t�. S30 _FROZEN DESSERT S40 TOBACCO S» �a�zE c��cE: sis AMOUNT DUE _ $ �-� *****PLEASE TLRti OVER A\D COITPLETE OTHER SIDE OF FOR�T***** !�� ' �� , . , . . . ADMINISTRATION i Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal C 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 j I Town of Yarniouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK j APPROPRIATELY IF PAID: � YES NO I MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 j 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, sha11 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 Department to schedule the inspection three(3)days ( pnor 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 I closing. j FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the � Health Department to schedule the inspection three(3) days prior to operung. i 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 obtamed 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. ' 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 January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN c THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY'THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: ��I6 ��► � SIGNATURE: S� /��- l ' � , � � � PRINT NAME&TITLE: � � t� v�.t +-J L�-Lv 10 06!10 � � � r • ' �\ The Comnionwealth o f Mrrssachusetxs Department of Industrial Accidents ; Nlk'aNfrrrs�I�aG� i600 Washington Street, 7"�Floor i Boston,Mas� 02111 a Workers'Compensation Insarance pftidavft;gnildiug/Ptambieg/Ekctrical Contractors � `�D°--��=�h''+"�t�• Plrase PRINT k�elbl� : � � narne• � k.s �` [C.C_�0 address: �o� � �— ------ ?r3 �2� s Y az��Y �; ��/�►' �w. f�� Z� : d � � $ - Q-� 3 s te: � work site location( address)- Lj am a homeowner perforcYung all work myself. Pro�ect Type: �New Construction ORemodel `�I am a sole proprietor and have no one working in any capacity. ❑gui��n Addition S ❑ I atn an employer providing workezs'compensation for my employees wocicing on this job. com nme- address: I � � citv- u6oae�k � � �' # ❑ I am a sole proprietor,geeeral coatrsctor,or homeowner(circ%o�u)and have hired ti�e contractors listed below who have the following worke�'compensation polices: co address• ' ciri: D�Os!M �ffiBilOC!CO. # . �IYlf' CHYL D�O�!k �OS !p, # ��., ��!�r� Fait�re te xeme osreraae n reqdr+ed��dv 3eetls�ZSA st MGL 132 w Ind b tYe��f vf�dai °k Y«n'�mprMo��mt an wdl as dv/peaaltla In th fer�sf a 3TOT WORK ORDER aed a�d 5100.O��a da�•f a Sae�p b i1,3ilM aadfK eepy sf tYit staoemeat may 6e forwarded ts tAe Odiee of l've�tl�as of t6e DIA for esveraae�^erlAeatN�. y�ae. 1 nedentud tLat a /do henby ceroffy w�rder Nie palnJ awd penaltlef oJperj�ry tAret rlye iwfonwiq/on provlded oboae Is 1►we awd comct S,� , �1 . 1 �t� �5��6 /�� Princ name � R (�lktl,d / 3 Phone# ��"IJ� r�7 � et8cial ax oaly do not w�rMe la thh area te be rnuplefed�p cHy or 6swn oHkh1 ' �ity or tawn• ' � PermiMitense q �Baidina Depar�ent ❑eheck ff immdtlale re�peme is reqnircd ��na Board DSdectmes's Oroee t��mrsomo' pho�e M; QO h��rtisc�t Q