The URL can be used to link to this page

Home My WebLink AboutApplications, WC and Licensesi i ! ! e, ^r= ` " � TOWN OF YARMOUTH BOARD OF HEALTH rH � `� �� 'D � � APPLICATION FOR LICENSE/PERMIT�-.�9� ` � C 1 5 ��J08 .�e � �. �� * Please complete form and attach all necessary documents'by � ce`W r ��,�. Failure to do so will result in the return of your applicahon pac . NAME OF ESTABLISHMENT: Ct1n „ � �b'�, TEL. # ��` 7�� 'a�d LOCATION ADDRESS: 9 I � 4 0� �� t/141LMQ�` , �li+�i� a 8,,(p(p l.� MAILING ADDRESS: �l. OWNER NAME:_ �"� C Q,U C�1�. TAX ID �FEIN or SSN�: CORFORATION NAME (IF APPLI� LE): � MANAGER'S NAME: bC.. �'��l`L/2 TEL. # r;dQ ��O 6 -�� MAILING ADDRESS: q� 1 T • �� S�� y}�-Ui,Qu L oa(� 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 cei�tification to this form. � 1. 2. Pool operators must list a minimum of two eniployees currently certified in basic water safety, standard First Aid and Community Cardiopulmonazy Resuscitation(CPR). Please list these employees 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 your place of business. 1. 2. 3. 4. ; FOOD PROTECTION MANAGERS - CERTIFICATIONS: � All food service establishments are requued 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 certificatian to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file Rt your establishment. 1. `�OQ. � ��V1�t��- 2. � ��'�� PERSON IN CHARGE: _ _ _ _ _ __ _ _---- —___ _ __ - - --------- __ - � Each food establis ent must have at least one Person In Charge (PIC) on site duritig hours of operation. � � 1. 1'2� �1��/�i �� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heiinlich Maneuver on the premises at all tunes. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications ta 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- RESTAURANT SEATING: TOTAL# �FFICE USE ONLY LODGL'VG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# _B&B S55 _CABIN $55 _MOTEL �5� _INN 355 _CAivIP ��S _SWIMMINGPOOL �80ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $8dea. FOOD SERVICE: LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREb FEE PERMIT# / 0-100 SEATS �85 �6��!g _CONTINENTAL S35 NON-PROFIT �30 _>100 SEATS �160 I COMMON VIC. $60 �O -'6 '�/ _WHOLESALE �8Q RETAIL SERVICE: —RESID.KITCHEN �80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEB PERMIT# _<50 sq.Yt. ��0 >>25,000 sq.ft. $225 VENDING-FOOD �25 _<25,000 sq.t�. 580 _FROZEN DESSERT $40 I'OBACCO ��5 NA�IE GHA:�iGE: �lo AMOUNT DUE _ $ /�S,d� *****PLEASE TUR�OVER AiV'D CO.'VIPLETE OTHER 5IDE OF FORIVI'*'�** r . ^ . � . i ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hald 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 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 MOTELS AND OTHER LOD�ING ESTABI.ISI�NIENTS 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 ofresidence 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 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 ins ected ' by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(S�days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been mspected and opened. .; POOL WA1'ER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, 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 � 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 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 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 establishmern is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBII.TI'Y TO RETLTRN TF� COMPLETED RENEWAL APPLICATION(S)AND REQLTIIZED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED$�THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT PLAN. �'----. DATE: f� �g SIGNATURE: ' �1\/ ' PRINT NAME&TITLE: �6'Q_. �1 �U`?R/��- 0 (,UN�P.� '' io�2iios � � I � " ' � , � � � The eommonwealth of Massachuselts � Department of Industrial Accidents � �� 600 Washington Stree� 7`�Floor ' Boston,Mass. 02111 Worlcers'Compensation Iesnra�ce Affidavit;Bailding/Plambing/Ek�ctrical Contractors _ �: z c' Qcl �-Ct �.J1. aa�s: �' f /'�� a� citv �` Y �"�MQ � state• �� zio• n o��l�� ohone# >�g "7UJ o 'o�.g 7`9 work site lceation tfull addressl_ �I am a homeowner performing all work myself. Project Type: ❑New Constcvction�Remodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensatian f�my employees worlcing on this job. � ` -� `�}�: : _ _ _ __ ce� samr. - - _ ,��: q�( l ` ` $ �.� �h.h�o� . p �#- �o� 7� � .-a�� ciri: � 1 U"t IZ" ulroa ca � .� - .�;: ,. , .. �.F .�,:��:�: �.,�«,:� ». ,:_ ❑ I am a sole proprie�or,gegeral eoetractor,or�omeewner(czrde o�re)and have hired tbe contr�actors listed below who have the following workers'compc,�nsation polices: coe�minv eaate• addr�ess• cilr nkoue A. iwsvt�ee ta # , ..:,: ,: . . ,: ,.. .; �: _ ,..s >;, < : ,. ,.: _ - . k.�:.;,� '. oe�oaav Dame• �: c,itp: �#. _ _ ___ -- — _ _ --- __----------- --- --- --- ------- iea co. # ,_. . .: .:;. ..,_ . ;., . > . : � � ;;: �r . ; 3 5,:t; � �,.• �•• • :�.: . �,aa,, <•• '.. , r. � �� .�.�.::3 �?4, .�,•� . Fai�rc Os secm�e ewaaEe as reqnired a�der Seel�a 2SA�f MGL 152 ea�lead t�fke�rf crisioal pnaltla�f a�ae�b S1,SA6.a0 aud/� �Y�'��t as weY as dvY peaaltlea in t6e forn�a STOr WORK ORDEA aed a 8ne ef 5160.AS i day sgaimt de. I�td that a c�py qf tl�a stahmeat my 6e forwarded/s t�e Ot�erof.�uvptig�flo�s ot tlte DIA for to�erage v�er�atl�e. / /do beneby c��tlie paires axd lNea ofPtrjxry tllrat NYe iwfonwaHo�provided abov�e is due awd S�gnat°i'e Date % �� O Priat name �- �,�`C./ Phone# �� 6� a:�� effiMial ase AoFy do not write�this atea te 6e oo�pleted 6Y cHy or iawa�ciai city ar te�vn: �� Boid�Depat�ment ❑chect if�me�a�e rc�eme b reqaired QSda�n s Offiee ��t ceattct peaaea: �� (��) 4 � . . , TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-118 FEE: S85.00 In accordance��ith regulations promulgated under authoriri�of Chapter 94, Section 30�A and Chapter 111,Section S of the Generat Laws,a permit is hereby graiited to: Joseph Chevalier, 941 Route 28, South Yarmouth, MA Whose place of business is: Cup A Joe Type of business: Food Service To operate a food establishment in: Town of Ya�mouth Permit expires: December 31, 2009 BOARD OF HEALTH: .�fQe�ee��r�t�S� f�c� ,�J�_�.a.l.lQ�.,��C'f��ya�v�rtta��rc�� SEATING: lO �7�[�I�(XA .76, �/L�LUlWi. V/� �.�KIU[!lLllfL ��,""""'acc�'�2t?� ��• �� Januan�8.2009 � Bruce G.Murphy, H, .5.,CHO Directorof Health .��,�,�_�,��__. . ., � . �..x _, �. .. �_ ._ . � . � ._ . ____ _ __ . THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH PERMIT NUMBER: #09-079 FEE: �60.00 This is ta Certify that Jose�h Chevalier d/b/a Cu� A Joe 941 Route 28, South Yarmouth, MA IS HEREBY GRANTED A . COMMON VICTUALLER'S LICENSE In said Town of Yarmouth and at that place only and expires December thirty-first 2009 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in conformity with the authonty granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersi�ned have hereunto affixed their official signatures. BOARD OF HEALTH: 3�eeeit S�, J�Z.JV., C�c�ixtaart sEArmc: �o C'.fiEarx�eo .3�. 9Ce�i/tex 21ice C'l�ainntctn J�Ct 3. ��awn, e� Qtua (�'�ceer�dEaccun, J2..A�. E'ue�c�• ��l,e� January 8,2009 ruce . u y, , • •, Director of Health