HomeMy WebLinkAboutApplication and WC _ �
, ' � TOWN OF YARMOUTH BOARD OF HE�'T.� � .:. �!'� i a�v��2
APPLICATION F4R LTCENSE/PEItMIT*3A1C� �:', ;, �
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*Please complete form and attach all necessary docum�'by��4��er 1 S 2009.
Failure to do so will result in the retum of your application pac et.
NAME OF ESTABLISHMENT: ��° L-'T�-�-�`��L TEL. # sb�-�7�'�a1ov '
LOCATION ADDRESS: �g z� t7�r- Z-�- c.J• c�i�z�. '
MAILING ADDRESS: '�-�-�e. :
OWNER NAME: ��2.��L� "V� ���C- � L TQ.�ID (PEIN or �SNI:
CORPORATION NAME(IF APPLICABLE): S'�
MANAGER'S NAME; ��C� �/ti+t�c TEL. #�r-'o� �'-7� �lr�
MAIL�NG ADDRESS: �_�A�
POOL CERTIFICATTONS:
The pool supervisor must be certified as a Pool Qperator,as reqnired by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificarion to this form.
1. �''�i.cr�-tvS ��5«y-�-+'S 2. .
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitation(CPR}. Please list these emplayees b�low and attach copies o�employee
certifications to this form. The Health Department will not use past years' records. You must provide new
copies and maintain a file at your place of business.
1. � S ����� 2. +�`���,,,,�,��i,:�
3. �.,..� 4,
FOOD PROTECTION�vIANAGERS - CERTIFICATIONS: ;
All food service establishments are required to have at least one full-time employee who is certified as a Foad '
Protection Manager, as defined in the State Sanitary Code for Faod Seivice 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.
1. 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 2S seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all ti.mes. Please list your emmp loyees trained in anti-chokuig procedures below and
attach copies of employee certifications to this form. The Health Department will aat use past years' records.
You must pravide new copies and maintain a ffle at your place of basiness.
1. 2.
3, _ 4.
RESTAURANT 5EAT'1NG: TOTAL#
OFF'�CE USE ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENS�REQUIRED FEE PERMIT#
�BBcB $55 �CABIN $55 1,MOTBL $55 '� 0—U
____lIVN $55 �CAMP $55 I SWIMMING POOI, �80ea. {�` O^O��
,_,_LODGE $55 �TRAILERPA.RK $105 _ ,,,_WHIRLPOOL $80ea.
FOOD SERVICE:
LICENS�REQUIRED FEE P£RMIT# LIC�NSE REQUIRED F$E PERMIT# LICENSE REQLJIRED FEE PERMIT#
0-100 SEATS $$5 �CONTINENTAL $35 GO��u�3 NON-PROFIT $30
>100 SEATS $160 COMMON VTC. $60 �WHOLESAL� $80
RETAII.5ERVICE: —RESID.KITCHEN $80
I,ICENSE R$QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT## LICENSE REQUIRED FEE PERMTT#
�<50 sq.8. �50 >25,000 sq.8. $225 VENDING-FOOD $25
„�<25,000 sq.ft. $80 _,,._FRQZ�N DESSERT $40 �TOBACCO $55
NAMECHANGE: $is AMOUNTDUE = $ I�O.00
**""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF'FORM"•"**
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AD1VIINiSTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuanae or renewal
of any license or pernlit ta operate a business if a persan or company does not have a Certificate of Worker's
; Compensation Insurance. THE ATTACH�D STATE Wt7�RI�R'S COMPENSATION lNSURANCE .
� 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 pemuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES_� NO
MOTELS AND OT'SER LQDGING ESTABLISHMENTS _�._
; TRANSIENT OCCUPANCY: For gurposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use.
Transient accupants must have and be able to demonstrate tha.t they mairrtain a principal place of residence elsewhere.
' Transient occupancy shall generally refer to continuous occupaney af not more than thirty (30) da.ys, 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 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, shall generally be considered Transient.
POOLS
POUL OPENING:All swimming,wading and wlurlpools which have been closed for the season must be inspecteti
by the Health Department prior to opening. Contact the Health Depaatme�t to schedule the inspection three(3)days
pnor to opening.PLEAS�NO'T�: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 far pseudomonas,total cnliform and standard plate cownt
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)d�ys of '
closing. '
FOOD SERVICE I
CATERING FULICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the require�i
Temporary Food Service Applica.tion form 72 hours prior to the catered event. These forms can be obtained at the
Health Department. ;
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension ar revocation of your Frazen Dessert Pennit untit�the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frora the Board ofHealth.
QUTDOOR COOKING:
(��c��cQols�ng,pr�par��io�or�i�p�yQf an�f�d�rod�ct_by a retail_or_food service_establishment is�r�►hibited. ,
N4TICE:Pernuts run annizally from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILrTY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 1 S, 2009. `
ALL RENOVATTONS TO ANY FOOD ESTABLISHCViENT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BO.ARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. t
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DATE: `����`QY SIGNATURE:
PRINT NAME&TITLE: �l�''' `�'� ���T- /�/L�_ "
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09l25/09 `
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The eommonwealth of Massachusetts
Departmer�t of Industria!Accidents
NAf�eNi�lf�s
600 Washington Street, �Floor
Boston,Mass. 02111
� Workers'Compeesatioa Iesera�ce Affidavit:Baildiag/Pi�mbiag/Ekctricai Coatractors
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work site tocation(full�dressk
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❑ I am a sole proprietor and have no one working in az�y capacity. Q Building Addition
[�am an employer.p�oviding w�ke.rs'compensation for my ednployees worlcing oi►this job.
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