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Home My WebLink AboutApplication and WC , � '� TOVf�N OF�'i'ARMOUTS BOARD OF HEALTH ,�'° G'��,►��t�° ; AP'PLICATION FOR LICENSEfPERMIT-20�o DEC 14 2'��9 *Please completc form and attach all necess�ry documents by Dece • tr i . Failure to do so will result in the return of your application p NAME OF ESTA$LISHMENT: TEL. #,�"ll,� ce��:4��3C� '' LOCATION ADDRESS: v ,� MAILING ADDRESS: OWNER NAME: — � F or N � / CORPORATION NAME (IF A.PPLICABLE): � o ' � MANAGER'S NAME: -z/ + — � TEL. #a,�"�—,��(� MAILING ADDRESS: o G .9 �c- POOL CERTIFICATIONS: p'�� /��7��/(�/ �L The pool supervisor mast be certified as a Pool pperator,as required by State law. Please list the designated ' Poal Operator(s) and attach a co�y of the certification to tJus form. ; _- - _l. __ .___ � � _ 2, �G�� --- Pool operators must list a minimum o£two emp loyees currently certified in basic water safety,standard First A.id and Conamunity Cardiapulmanary Resuscitation(CPR). Please list these employees below and attac�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 yonr place of business. �. a. 3. 4. F(70D 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 not use past years'records. You must pravide 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 (PTC) on site during hours of operation. 1. �1�,�� 2. � HETMLICH CERTIFICATIONS: i All food service establishments with 2S seats or more must have at least one employee train�d in the Heimlich Maneuver on the prernises at a11 times. Please list your employees trained in anri-choku��procedures below and attach copies of employee certificarians to this form. The Health Department will ant use past years'records. ; You musf provide new copies and maintain a file at your place of business. 1. �C,`�� 2, i 3, �— 4. I � RESTAURA.NT SEATING: TOTAL# OFFICE USE dNLY ; LODGING: LIC�NSE REQUIRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT# LICBNSE REQUIRED FEE PERMIT# _,,,_$&B $55 „_CAB1N $55 �MOTEL $55 ��OJ� Av'N $55 ____Cfii4'� $55 �S�xlIMN�NG POOL $80�a. _LODGE $55 �TRAILERPA.RK $105 �WHIR,LPOOL $80ea. FOOD SERVICE: LICENSL REQUIRED FEE PERMIT# LIC�NSE REQUIRED F�E PERMIT# LICfiN3E REQUIRED F�E PERMIT# ,�0-100 SEATS $85 _GONTINENI"AL $35 �NON=PROFIT $30 >100 S�ATS $160 COMMON VTC. $60 WHOLESAL� $80 RET.�11L SERVICE; —RESID.KITCHEN $80 � LICENS�REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _,_„<50 sq.R. 550 >25,000 sq.R. �225 VENDING-FOOD $25 , ,,,�<25,000 sq.ft. $$0 _,,,_FROZEN DESSERT $40 � TOBACCO �55 NA11�CHANG�: sis AMOUNT DUE = S 5S•o0 '"***�L�ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** .`.-�. �11. . � j c� ADMINISTRATION : � Uttder Chapter 152; Section 25C, Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal � of any license or pemiit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACHED STATE WOItKER'S COMPENSATTON INSUI2ANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �f �/�� fi��J ld}/-P�� CERT. OF INSURANCE ATTACHED OR W4RKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK APPROPRIATELY IF PAID: ' YES NO � MOTEL-S AND OTHER LODGIl�TG ESTABLIS�#�AT'�5--- _. _ ___ �:_.�� ; �! TRANSIENT OCCUPANCY: For purposes of the limitations of MoteI 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 occupants must have and be able ta demonstrate that they maintain a principal place of resitdence elsewhere. j Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an f 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 eollection of Room 4ccupancy '' Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as arnended, shall generally be considered Transiart. , i POOLS � , POOL OPENING:All swimming,wading and whirlpools which ha.v c osed for the season must be ms�� ' bq the Health Department�prior to opening. Contact the He �artmetrt to schedule the inspection three(3)days i pnor to opening.PLEASE NOTE:People are NO ed to sit m the poal area.until the pool has been inspectecl ; and opened. � POOL VVATER TESTIl�TG• e water must be tested for pseudomonas,total coliform and standard plate count � by a State certified 1 submitted to the Health Department three (3) days prior to opening, and quarterly � thereafter. _ �— — C ; POOL CLOSING: Every outdoor in ground swimxning pool must be drained or covered within seven(7)d�ys of � closing. � FOOD SERVICE � CATERING POLICY: � Anyone who caters witban the Town 4f Yarmouth must not' armouth Health Department by filing the required � Temporary Food Servics Application form 72 haur ' r to the catered event. These forms can be obtained at the ` Health Department. � FROZEN DESSERTS: Frozen desserts must be t on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failur o so will result in the suspension or revocation of your Frazen Dessert Pemut untit the above terms�Za een met. � t OUTS E CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: ' Outdoor cooking,Qre aratio�or display of any food product by_a retail4r food service establishmern i�o�Libited._T= , � NQTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBTLTTY TO RETiTRN ° TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED F�.E(S)BY DECEMBER 15, 2009. � ALL RENOVATIONS TO ANY FOOD ESTABLI MOTEL OR POOL, i.e. PATNTING NEW � � EQUIPMENT,ETC.),MUST BE REPORTEI� APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENpVATIONS M UTRE A SITE PLAN. � � DATE: G9� � � � SIGNATURE• � PRINT NAME&TIT : icl � T tz � D C</�cE'G i'i' i srl•+��1�'-2vQ � G�j0�2lC�I�� 09125/09 � I 1 _ , � , _t ' � . - ` ?'he Cominonwealth of Massachusetts Department of Industrrial Accidents NAft��f�a1�s ' 600 Washiagton Street, fh Floor Bostoa,Mass. 021I1 ' Workers'Compeasatio�iesarance AtTi�d9vit:Boilding/Ptambi�g/Ekrtrieat Contractors A��e�t isfermEst�s P'leaare PWI�TI`k�ibN . _ , n�- /�"��2 y� �. �c�rJr�-� address: 1�� l L� �� cih+ 1G Dlll�/�1 � �/rZl/L�l�! shate• �/� zi��u�� phone# work site lceation fiill address: ` Z/ /r✓ /a � � I am a hom�wner performing all work myself. Project Type: New Ca�struction Remodel I am a sole propridor and have no one working in any capacity. ❑Building Addition _--�_ i am an employer.providing workecs'compeasation for my employees working on this job. eom�an�mmer _ _ _ _ _ address: citl�: oliaae#• irs ca , , , ... . . . ... . ; ,., ... . . �� .: n . ,s„ ��r.,:�:,.�.r.,:'.�.a�^3 '�u�{�a��'4�.�?�i+:c�3>_; , ❑ I am a sole prapriefor,geaeni co�tracta r omeowaer( � ow�)and have}ured tbe�tors listed below who have ' the following workers'compeaSation polices: _ , co��v rame: . . ? . - _ _ . addraaa �' nkore#- � i�sarasce eA. # ,. ..� . � : . .,. �.:�k�:: �.;e� ��ss,�':'-�.��; cs�eur�mc: address• c[t�: , oiioiae Ah _ —_ w__ — .�— , .: . . ,.. ,. .. , � • � '- �.r{� - � :�- ' `c .z .�.. r�a 3�..?'` �.?b.-n�.��r.��+,. .XL.'r.,'�,.��a`�'�`�r'�,' x'�°'�^..�.'.�h�'«,..�` �. - , F�QY r 7lCQ!pYl�t!!I�E1��1O�!!��A��'�.�dl�L1d�mt��t�'��q�S�!!1p b�11�K ��e yeaT!'1�6�nt!!w�if lIMI p�altles�ti!t0[��f a 31'01'WORIC URDBR!1d!1�t�[fllS.N a day a�re.1�sdas�d t�t! eep��ttl��ta�eac't my he tetwu�ded M t4 Omoe�tlave�Ha�s of IYe DIA 6er a�sra=e x�. I lo ltd+eby ce ' d �we1 d lw a�ion provided aboae fs bTrE iwd o�rnct _ Dau �C �. o��U� �� - � � � ��J�-=,�,T� (>L3� ��, aa.oc.�r.�u�co�«�a er.�xr K�..� . ' d�Y K r•�: ,'_p�e s f 7eeY�Departmme ❑eYe�t if�1e ie�sese 6 reqai�+cd , �� O�a QIInMk Deparf�t a�tact pelsan: ��; []p�� (�d�� ,