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Home My WebLink AboutApplication and WC ____ _ � _ , � ► TOWN OF YARMOUTH BOARD OF HEALT� �''��`" � --��:L� „ � � APPLICATION FOR LICENSE/PER�►�T=��01 � ��_ ` � OwB 0 �� '� � � � S * Please complete form and attach all necessary�ocum�its,b� Decem er 1��2��2�!� { � , f Failure to do so will result in the return of yc�ur application pa et. � ; a _ ESTABLISHMENT NAME: L'�L"��-'��"�t. TAX ID: LOCATION ADDRESS: �q ��Ys.� � �t'�� TEL.#: 5'E��7 -v�o� MAILING ADDRESS: 't"�,�. �� OWNER NAME: �_��c-°`.r � � �� lI LL.� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �f � TEL.#: �8y �7-''�l�P MAILING ADDRESS: � 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 forni. 1. �� 2. � 4'e-��-c�,�! Pool aperators must list a minimum of t`vo employees cunently certified'ui basic water safety,standard Fust Aid a�ld Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of einployee certifications to tlus form. The Health Department will not use past y�ears' records. You must pro�ide ne�r copies and maintain a file at your place of business. 1. � 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requued to have at least one filll-time em�loyee who is certified as a Food Protection Manager, as defined ui the State Sa�utary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of cei�tification 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 establislunent must Iiave at least one Person In Charge (PIC) on site durulg hours of operation. 1. 2. I HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee ri•ained ui the Heunlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig 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`�our place of business. 1. 2. 3. 4. ' RESTAURANT SEATING: TOTAL # ' CIFFICE USE OlV'LY LODGI\G: LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PER\�IT� LICENSE REQUIRED FEE PERIVII7 tt _B&B S55 _CABIN S55 ��iOTEL S» ��I—DY� _INN S55 _CAivLP S>j � S�b%L��LVIINGPOOL S80ea. #//—d� _LODGE S» �TRAII,ERPARK 510� ��41IIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERNIIT� LICENSE REQUIRED FEE PER�iIT# LICENSE REQUIRED FEE PERMIT� � _0-100 SEATS S85 �CONTINENTAL S35 �, �I�� _NON-PROFIT S30 _>100 SEATS S160 _COMiVION VIC. S60 �'�'HOLESALE S80 RET.�IIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PERi�1IT# LICENSE REQUIRED FEE PER'�1IT� _<50 sq.ft. S50 _>25,000 sq.i�. S?25 VENDING-FOOD S25 _Q5,000 sq.ft. S30 _FROZEN DESSERT S40 TOBACCO S» �:��E c��cE: sis AMOUNT DUE _ $��O . O O **'�**PLEASE TtiR\OVER A\D CO�TPLETE OTHER SIDE OF FORJY*'�"�** � i ADMINISTRATION a , _ ' S 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 1NSURANCE ATTACHED '�''�� OR , WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED_� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEA5E CHECK APPROPRIATELY IF PAID: YES &'"� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shaU be limited to the temporary and short term occupancy, ordinarily a�nd 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 sha11 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. 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 srt 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 � R � i 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 opening. CATERING POLICY: ( Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required i 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,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. OIfTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. 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, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVV�NT, 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. ; i DATE: " J��fl�� SIGNATURE: � � ; f� PRINT NAME&TITLE: ' �o o6rio �, i DEC. 30. 2010 1 :SOPM , NART INSURA�CE � N0. 391 P. 1 . '�QR�n C�RTIFICI�TE 0� LIABILITY �NSUR/4NCE °"'�°"""°°'""""' 12130/20i 0 �ttoouc� THIS C�R71FiCATE IS ISSU�D AS A MA7T�R.OF lNFORMA710N HART IWSURANCE AGENCY, INC. ONLY AND c�F�s NO RK31iTS u� TfiE Cr�TtFICA'R 243 MAlN STREET ��- � ��T� � �T �ND� DCT�J�D OR a�� r� cov�a aFFo�� Y T++E Ro�.�c�s Baow. PO BOX 700 BUZZARDS BAY, MA Q�532-0TQO IW5uRE1iS AFFORD0�16 GOIIERACiC fi�UG� '"S�b lrish lfilia�Restaurant and Pub,lnc. ��: G 1'fE ST td RANCE 2 09 512 Main Streei ��rt� West Ysrmouth,MA 02673 � c: ��a �NSURER E GOVERAGES THE PULtC1ES OF INSlJRANCE LI$TED BELOW HAVE BEEN ISSUED TO TNE WSURED MMAED ABOVE FOR 7NE POf.ICY PERIOD INDIGA7ED.NOTWITFI$TAND8K3 ANY IIEQUIREMENT,TERN4 OR CONDfTtON OF ANY CONTRACT OR 07HER DOCUMENT WRM RESPECT Tp WFlICN TF118 CDtTM�IGITE MAY BE ISSU6D OR MAY PERTAfN,7HE WSURANCE AFFORDEQ BY 7'H�p0UC1ES DESCRIBED FIER6Ml IS SUOJEGT TO ALL 71iE T�,Q(CLUSIONS AND CONDfT10NS OF SUCM POI,�IES.AGGREGA7'E LMNfI'S SHOWN MAY NAVE BEEN REDt1C�0 BY PAID Ct.Al1A8. � a roui.w noucr ow.+w Poucr�re0e tiw�crs �re,a une�.rn �►cy a�cu��ae a COMMBftCU!GENERAL W4BttJ7Y i CUIM$MADE �OCdlR ►�) pl19 pef8an) � v�sonuu.s�+o�u+�urnr ` s �.�sart�on GEN'L AGCRE(3ATE LIM[F APPCIES PER PRpDUCT3.QqKP�AC9G f POI.ICY LOC Al1SOk10BILE tJA&L1TY COVBIf�D S�'+LE LIMTf s ANY AlITO (Ei ioaOMt) ALL QYYNED AtfT'OS ��Y�� S SCFIEOVLED AUTOS �� HrREDAu=06 gpp��Y IWURY Nor�owH�owros p'�� s �Daww@ s G�RA�E LN61f.(TY AUiO OI�Y-EA ACdDEKf i ANY A{Jf0 0'�ER TFUIN EA ACC S A!,lf0 ONLY' A� S E7(CE35NM8REt�A WB1t.rtY OCC{JR�CE 5 OCC�R �CW�SF�nDE � _ s DEDUCT�LE / RE7BNTION S s q vwoR�s��noNrwu VINC005855Q77 04101/10 Q4/01/19 a orri- AM PROPRIETORIPARTNERlFJ(ECVntr� E.� M L"IOENT s � O��CER�►�MOER E%CWOE07 EL Ot8EA8E-FA�iPLdYEE S �QQ uy9�,aaaerr�e w,aer 3P GAL PR e NS ENew F��qEqg�.p��,!I� S 07MER DE�RIPlfOM OF bPSRA?IONi 1 LOGT�MS 1 VEiMCtL�S t DfCW&ONS ADD�9Y 1 SPECIRL PRONISIOIIS CERTIFICATE HOLDER CAMCELLATION SMQIN.D�1Y�111E AfOY!D�lp rOUCRi 9!CAqCBllD 9lFOR!Tf1E lXPdlA7fIN1 1'OWN OF YARMOUTN °AT��''��""�'"`L�"101�fO1MA1�°i"Y' w�' 1148 MAIN STREET wrancE ro n��e��rn r��r.�s w�e ro 0o so� S YARMOUTH, MA 02673 , arrou"°°w'w`"°"°""�ea'rr°f"""'nA""°"'e��,rr'"a�'°" REPR696NTA �trrU01tR[D acoRo 2s�oo�rosf . �,�c��o�.��