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Home My WebLink AboutApplications, WC and Licenses! ` - TOWN OF YARMOUTH BOARD OF HEALTH , �� °D APPLICATIUN FOR LTCENSE/PF,1��T='2�10 � , � r �,.�.13� DEC ? i i�:a419 *Please complete form and attach all necessary doct�m�nts by Decemb 1 � Utr� . Failure to do so will result in the return a�your�pplication pac NAME OF ESTA$LISHMENT: C:`� I� \TD�. TEL. # 5Q� ��7(od-agg� LOCATION ADDRESS: q �j i �� • a� S� '� ��C an n ur �— MAILING ADDRESS: 5 � OWNERNAME: d2. Ja �1� FE Or N � CORPOR.ATION NAME (IF A.PPLICABLE): MANAGER'S NAME: ��"M1'��. TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated __—Poo1 Qperat��an�attach�cQpy_Qf�certificarion� this_form._ _ _ _ _ _ 1. 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 employees b�low 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 your place of business. 1. 2. 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 Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will nat use pAst years'records. You must provide new copies and maiatain a file at your establishment. l._� 6S�� eU � � ��- 2. --,- PERSON IN CHARGE: _ _ - - --_____— _`�---------- - - c oo es a s ent mus-have atTeasfone Persozi InZ"I1ar e IC n srte�urin hours of eration. � (P �-__ � - *- � p �. � ns �� e.vA� 1�� 2 ��T�-P�c'. � �U��`C��C� HEIMLICH CERTIFICATT4NS: 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 rimes. 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 maint�in a file �t your place of business. 1. 2. 3. 4. RESTAURA.NT SEATING: TOTAL# �� OFFiCE USE ONLY LODGING: LIC�NSE REQUIRED FE� PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B&B $55 �CABIN $55 rMOTEL $55 INN $55 �CAMP $55 �SWIMMtNG POOL �80ea. LOD4E $55 TRAILERPARK $105 WHIR.LPOOL $80ea. FOOD SERVICE: LICENS�REQUIItED FEE PERMIT# LIC£NSE REQUIRED F�E PERMIT# LIC�NSE REQUIRED FEE PERMIT# �0-100 SEATS $85 �� .,_,_CONTINENTAL �35 �NON-�ROFIT $30 >100 SEATS �160 �COMMON VIC. $60 �0�� WHOLESALE $80 RETAIL S�RVIC�: —RESID.KITCHEN �80 LICENSE R�QUIRED FEE PERMIT# LICENSE REQUI1tED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT# �<50 sq.ft. �50 >25,000 sq.R. $225 �VENDING-FOOD �25 Q5,000 sq.ft. $�0 _FROZEN DESSERT $40 �TOBACCO �55 NAME CHANGE: $is AMOUNT DUE = S �5 .O Q , "'"**�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**""* \ . . - . � - r , ADMINISTRATION ', t � Under Chaptex 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATTON Il�TSURANCE � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR , � CERT. OF INSURANCE ATTACHED . ' ` � OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED � Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yaur permits. PLEASE CHECK ' APPROPRIATELY IF PAID: /� � YES ` NO � ; MO'TELS AND OTHER LODGING ESTABLISHMENTS Tl,2ANSIENT OCCUPANCY: For purposes of the limitations of MoteI or Hotel use,Transie�t occupancy shall be ` limited to the temporary and short term occupancy,ordinaril�and customarily associated with motel and hotel use. Transient occupants must have and be able to demonsirate that they maimain a principal place ofresidenee elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than t.�irty (34) 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Oc�cupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as atnended, shall generally be considered Transignt: f _ _ _ , POOLS I POUL OPENING:All swimming,wading and whirlpools w}uch have been closed for the season must be insp� by the Health Department�priar to opening. Contact the Health Departmetrt 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 TESTIl�TG: 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 paol must be drained or covered within se�en{7)days of clasing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the eatered event. These forms can be obtained at the Health Department. FRO�EN 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 s�xspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor sea.tin�with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOI�TG: Dutdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � _ _ __ _ _ ___ — ___ __ __ _ E NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISH�VCENT, MOTEL OR PUOI, (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN '1 _ / , DATE: -a /� d� SIGNATURE: � � PRINT N.AME&TITLE: b`e- e-v�� " (�(�J�`ef C 09l25/09 � �� _ �, r � { ~ �\ The Commonwealth of Massachusetts Departneent of Industrial Accidents �� 600 Washington Street, ��'Floo� Bostoa,Mass. �Zlll . Workers'Compe�Noa I�ara�ce Affidavih B�ilding/Piembing/Electrical Coatraetors t �: �os ep � c �t/p� � er�. address- —1 � i�'� � �� c� �� I lT'K MOtj'C state: U �1� �p_ V�bV"l pha�e# ✓C�•O !tQ� oZ.�� work site location ffiill addressk ❑ I am a hom�wner perfomring all wark myself. Project Type: �New Constn�tion QRemodel �,I am a sole proprietor and have no one working in any ca�city. ❑Building Addition ❑ I am an�nployer pToviding workers'compensati�for my employ�s wodcing an this job. --- _----- - ��-�-� --t�-� �..- ---- � _ ,. ___ —_- --,_ __ comaano aame- - ��: q�t �z� � a� : dri. �� y�rC D�� - 7�$ - �� . :.:.. . '. . ��. '. -,::a�� 5;;::"� ' - -F"- -,•�• >..:,:.�' u..:.%: .� ..,,�? , •d.�£:f f?�4-�v.+�'+...?y+ Q I am a sote proprie.Eor,g�era!co�tractor,or�omeowner{cirde one)and have lured the contractors listed below who have the following worlc�s'compencation polices: t'AmD�rY�!: �- . . . �. . . .. . . . .. . , . .. f�881 C�LY' : pd6Y!(�' _ � l�lQ�IC!M.� . � � . - . . . . . # - . . . . _ _ . . . . . , . • ^��_. fi-:=�.� - . <.+_;� c�c::.. ��:.�,�;�; :g.r��,�. S�IDitf Lme: f�' �: p�pM�' -- --- - -. �. _ _ -- - —__ ----.� --- .. . . . ��> .. rr�:i t �;�-�'s :�x �<,3*`: �°, �:? 'x-i- „�� . ..��`.:�-�,. - °��::�e �_�°'�`�-�° ;� . Fai�rc r see�e a+e�e n req�i�ed uder Satl�a 2SA�f MGL 152 eae le�d h fYe�Mr�f a�d penaNks�f a�e tp h;I,SM.N aodl�r eae yan'isptiMawe�t a�wdl as dH pnaltla 4 rie Grai eta 31'Ot WOItIC ORDER aad a Bse s[s10s.N a day apidt a�e. I�eAe�s4�d tbt a apy�[fiir�m�be t�wuded N the Omce �[tYe D!A t�avsra�e verUlaliee. L 10 karby ' xeder e patns�P��` ofP�Y r!'tk�tlit isfonrrelton��vided abov�e is�rae Rwd � � a j� o� �-�- ,. g � . /_a � ��$ Print name V(�� G��,. �� Phone# � �YJ affidal�se�Wy do�at wrife�t6i�area t�be or�piefaed by.cKy er bwa�effieid . _ �'9 K�� ; peta�ifl6o�se� I�lBaidi�Depar�et �� ❑ekect if��e r�npsme is reqired QSdee�es's O�oe QHeaNk Dq�ar�at ��+'� pY�e!; OOtl� t��) .