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Home My WebLink AboutApplications, WC and Licenses ��,� . _.w�� r Jt.YA� TQWN OF YARMOUTH BOARD OF., , _, ,(3�`��=.;, � , ....-, � .� � � . H� � ::,�°� . .: ` ° � Y � � APPLICATION FOR LICENSE/P �.�0 � ,�� s� ° ~` � "�'`�`' `a : .aw �� t. ' - :__ -.. � - * Please complete form and attach all necessary c��cumf�it��y December 3 , tl " ' ' �; B `'�� Fazlure to do so will result in the return of your application packet. NAME OF ESTABLISHMENT: '�� -P.� TEL. #` ' ��' LOCATION ADDRESS: �c C� fJ"��6 MAILING ADDRESS: � G� �'& fl . � OWN�R NAM�: ��1 , TAX D E1N r N � � c'Z� 03 CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: j�l�I�( TEL. # 1— ^ 3t� 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 form. 1. 2. Pool operators must list a minimum of two em�ployees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee eertifications to this forrn. The �ealth Dep�rtment will not use past years' reeords. 3�ou tt�t�st provide nev�� copies and maintain a file at your place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS_ All food seivice 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 Establislunents, 105 CMR 590.000. Please attach copies of certificacion to this applieation. The Health Department wi�l not nse past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. _P�R�91�T IN��AR�E: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. ��ite1 ��,�- �. �" � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The I�ealth Department wiil 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 # � � OFFICE USE OnLY LQDGING: LICENSE REQUIRED FEE PER'�IIT# LICENSE REQUIRED FEE PER'41IT� LICENSE REQL'IRED FEE PERVIIT� B&B S50 CAB1N S50 MOTEL S50 INN 550 CAl�IP S�0 S�L7vLVIti�iG POOL 575ea. LODGE SSQ TR,4ILERPARK 5100 �lT-IIRLpOOL S75ea. FOOD SERVICE: LICET�IS£1tEQUIRED FEE PERMIT# LICENS£ItEQL?IRED FEE P£R�<fIT� LICENSE REQUIRED FEE PERYIIT= ( 0-100 SEATS S75 0$��r7'� _CONTINENTAL S30 _NON-PROFIT S25 >100 SEATS S150 CO:�LVION VIC S50 �L�-IOLESALE S75 RETAIL SERVICE: —RESID.KITCHEN S75 LICENSE REQUIItED FEE PERMIT� LICENSE REQUIRED FEE PERti1IT w LICENSE REQL7RED FEE PER�fIT� _<50 sq.ft. �45 >35,000 sq.tt. S200 _VEIVDIIvG-FOQD S?0 _Q5,000 sq.ft. �75 _FROZEN DESSERT S3� _TOBACCO SSO va:�cxa�vcE: sio AMOUNT DUE _ $ 75.��C7 *****PLEASE TL'R\OVER�\D CO�ZPLETE OTHER SIDE OF FOR�1*�*** l � _ __ . _ .� ADMINISTRATION � 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 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 LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel us�: 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 s�(6)manth period. Use of a guest urut 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. * NOTE: Enciosed Motel Census must be completed and returned with this appiication. POOLS PQOL 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 Department to schedule the inspection five(�days pnor to opening. POOL WATER 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 POLICI': Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmerrt by filing the required Temporary Food Service Application form?2 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 urrtil 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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernnits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED APPLICATION(S)AND REQUTRED FEE(S)BY DECEMBER 31, 2007. ALL REN4VATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY TI-�BOARD OF HEALTH PRIOR TO COMMENCEME�tT. RE�tOVATIONS MAY R Q RE A SITE PLAN. , DATE: 8 '�S— �� SIGNATURE: PRI:�TT NAME&TITLE: � � io;o o� � ' � The Commonwealth of Mussach�rset�s Department of Industrial Accidents NN�SN�w�lif�s : 600 A'ashington Street, 7""'Floor Boston,Mass. 02111 Workers'Compensadon Ia48rsnee Affidsvih Bnilding/Plambing/Electrical Coatractors A�a�t��t/i�. P`kaee p�tINT k�iblv n�: 5ah,.� �.��` ��(��,,-� address:�T�� [��e citv � r�01��1 state: t f i��s. zio: ��phone#�e��'�� wotk site location(full addnss): t�a ��11-3��8�� . v�� Ti�- am a hom�wner performing all work myseif. —�Project T : ❑New Canstruction�Remodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an employer providing workers'compensation f�my employees wo�cing an this job. wmpsav�e- V 1"f41.� 1�.1�1��' address• "V l 11lliU Dvl b� �� Gri: �3�.V �� S� ��c� �#: f—�' �l—�lo�—��.� � �. � ... _ : ,. ... .. ,;;. . . : ., x:.,:, � .. . ❑ I am a sole praprietor,geserst coatrsctor,or homeowaer(cirde one)and have lrired the co�actors listed below wlw have the following workers'cflmpensation polices: c�muaav,ame• addreas• citv uhoue#: i�saraace co. # �_.. � ..�;, z . .: como�av eame: �ddress• cttv: nlioae#• ea # ,_. A��ilwmet��. , . ; , . ,:: . , . ., .,; Fa�are bo sccme orvvage as req�ired a�der Satloi ZSA of MGL 152 eaa Ind t�tie��ef cdsteal pnaNks�a Sne�b 51,5la.a9 aadlor o�yeRrs'leapt6oement as weB�s civY peealtlea In t6e farm ot a 3TOP WORK ORDER and a 8ne et 5160.N a day�t me. 1 aeders4ad t6at a cepy ef tl�ia stalement may be farwat+ded/o tAe O�ce etlmesflgadem ot the DIA tar ceverage veri8afke. t do I}ereby ce ' a der Nie pniws and pexel' of perjrrry hket tJie inforr�atton provided oboae is trxe und correct s�� , �- nete � �r�� --�� Print name . �� Phone# � ��! offiMial nx oaly do not vrrke f�t6is ara to 6e completcd 6y city or�wn a�cial city or tewn• permit/Heenae# �Baidiag Depar�ent ��im8 Board ❑ehcck if�me�a�e nspeme is rcqaired OSdectmen's O�oe OH�NNti Depar�ent rnntact person: phe�#; (]Oth� t��+) I TOWN OF YARMOUTH BOARD OF I�EALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #08-175 FEE: 75.00 In accordance with re�u1arions promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the .t`'ieneral Laws,a permit is hereby granted to: John F. O'Rowke, 144 Old Townhouse Road, SouthYarmouth Whose place of business is: Jake's Bakes tOld Townhouse Park Concession Stand) Type of business: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31. 2008 Boaxn oF HEAI,TH: .�f.el.en S�ar�, J�.JI!, Cl�a�rnuui ��crxPee �. 9Cellillr�x `t�ice C'�awrmacrc ✓ta6�xt s..�vun,e� Qruc(�C' ee�cLfr�rcun, :I�..tV. �c�e�t 9'•.�fc�e�e September 3,2008 ` Bruce G.Murphy, .5.,CHO Director of Health