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Home My WebLink AboutApplication and WC 1 t ~ �� "� TOWN OF YARIVIOUTH BOARD OF HEALTH �� r�� .. •. � „�, _ APPLICATIUN FOR LT � .':. p��I9 ZJ1Q *Please complete form and attach all n ' ;t�y` c � �„�-�-��- Failure to do so will result in th � ' u pp catio � NAME OF ESTA$L�SHMENT: �.! �S A T� ,� TEL. # '.,2�- Cfy/� LOCATION ADDRESS: r0�v MAILING AUDRESS: OWNER NAME: D FE or � ' CORPORATION NAME (IF APPI,IC LE): � MANAGER'S NAME: ,,�f r CGJ Yf l TEL. # I,� �(�/a MAILING ADDRESS: ��c�,�rQ ' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. l. 2. Pool operators must list a minimum of two emp loyees currently certified in basic water safety,standard Fust Aid and Community Cardiapulmonary Resuscitation(CPR). Plea.se 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 fle at your place of business. 1. 2. 3. 4. ::s-� 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 af certification to this application. The Health DepRrtment wiU 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 durin�hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All foad service establishments with 25 seats or more must have at least one employee trained in the Heiumlich Maneuver on the premises at all times. Please list your employees trained in anti-chokuig procedures below and att�ch 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 at your place of business.. 1. 2. 3. 4. �'I RESTAURA.NT SEAT'ING: TOTAL# OFFICE US� ONLY I� LODGING: LIC�NSE REQLJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# „�BBcB $55 `CABIN $55 _MOTEL $55 INN $55 �Ce�MP $55 ,�,_,SWIMMt�1G FOOL $80ea. _LODGE $55 �TRAILERPARK $145 ,�WI3IR,LPOOL $80ea. FOOD SERVICE: LICENS�REQUIRED FEE P�RMIT# LIC£NSE REQUIRED �'�E P�RM1T# I,ICENSE REQUIR�D FEE PERMIT# �0-100 SEATS �85 ,�,j�,-0_„_� _CONTINENTAL $35 NON-PROFIT �30 >100 SEATS $160 �COMMON VIC. $b0 a�ZZ �WHOLESALE $80 RETAII.SERVICE: �RESID.KITCHEN �SO LICENSE REQUIItED FEE PERMIT# LICENSE REQUITtED FEE PERMIT# LTC�NSE REQUIRED FEE PERMIT# _,_„�50 sq.R. 550 >25,000 sq.ft. $225 VENDING-FOOD $25 „�Q5,000 sq.ft. $80 �FROZEN DESSERT $40 �TOBACCO $55 NAME CHANGE: $is AMOUNT DUE = S !'�5.O(S � "**"*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"** ._.._ .. .. . � � �� ADMINISTRATION �y-= ` 3�,.. . � # Under Chapt�r 152, Sec�ion 25C, Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal af any license ar pernut to operate a business if a person or company does not have a Certificate of Worker's Gompensation Insurance. THE ATTACH�D STATE WURKER'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 ta�es and liens must be paid prior tv renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO _ . __ _ - _ _.. MOTELS AND_QTHER LQDGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the teinporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use. Transient occupants must have and be able to demonsfxate that they maintain a principal place ofresidence cLgewhere. 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 sha11 not be considered transient. Occupancy that is subject ta the collection of Room Occupancy Excise, as defined in M.G.L. c. 64�or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POUL 4PENING:All swimming,wading and whirlpools which have been closed for the season must be inspecteci by the Health Department�prior to opening. Contact the Health Departmer�t to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool azea until the pool has baen inspected and opened. POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total cnliform and standazd plate couttt by a State certified lab, and submitted to the Health Department three (3) days prior to openin�, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days a� clasin�. F40D SERVICE CATERING POLICY: Anyone who caters witlun the Town of Yarmouth rnust notify the Yazmouth 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 suspe�sion or revocation of your Frazen Dessert Permit wrtit 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: _Qutdoor coolcinst.�r�ratioa or displa�of any fQod prQduct py a ret�or food�er�ic��s��blishmerrt is pr�hibited. _ NOTICE:Permits run annually from�anuary 1 to December 31. IT IS YOUR RESPUNSIBII.ITY TO RETU.RN TF�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENUVATIONS T4 ANY F04D ESTABLIS�-�V1ENT, MOTEL OR POOI, (i.e., PAINTING, NEW EQUIPNIENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HE.ALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. _ DATE: �� / �6l l� SIGNATURE: �titiu�,�'t-� PRINT NAME&TITLE: �`�I�� /`'�u � d�� 09125/09 } ' � � The Coinmoawealth of Massachusetts Department of Industrial Accidents �N�(lf�s 600 Washington Street, f�Floor ' Boston,Mass. 02111 + Woricers'Compeasallon I��ra�ee Affidavit:BaildiaglPtambiag/Electrical Coatraetors t �_ r'c�! � address- � � b' citY �• �/u��U�� state• /-/� yip• ��lr� `f' phone# work site location ffiill address): ❑ I am a homeowner perfom�ing all work myseif. Project Type: ❑New Construction QRemodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ❑ I am an etnployer providing workers'compensation f�my�tployees worlcing on this job. _ oom�m�B�mts addreas- : _ city' okose�r tea co. ; � ,. . .,.:;. �.. ..;, _w:-:i. .. . ;:: , t:- .s_ ..:,� _a«:�. . �:. .��*-�;��:��-„�a ❑ I am a sole propriefor,g�eral coetractor,or 6omeowwer(circle oirej and have hirad tbe co�ractacs�listed below who have the following workers'wmpensation polices: o2mwwv�a�e: . addresa: citv n6oac g• _-. iestaa�oe co. � . ,W_ �.-,.� . . ,- z:�: �.�,��.��.•. eonn�v�ame- add�ras- d�a ��k- -im�a�ee Eo. ___ ^ ---- -- --: ---- -- -- . ,...:w. ... . . # --_ __ , , .. ry,�,,. , � -' . -.: _r ,�� y ...a.� s �s "''":x ,�.?*,.,."..:3,!'�+eY'Ps..�'�:�`Y`. -.,::�r�r;-,�'-��4.�.,•��'i-`�' .,..-.�,r . Fa�+e r 7a�e or►eraEe a�reqired odQ See�2SA�[MC�L lS2 n��lyd a/Ye��fcr�ial pdaltla da A�e�p b;1,SA0.�0 atdfK ae y�nn'Ispr�t a we9 u ciM pe�alUa h tie 6rr K a STOI'WORIC ORDER a�d a ese�[S1N.N i day�se. 1�edaahad tbt a npy�[fii�sfale�t my be i�twarded M tle Omee o[l��f lre DIA fir a�nen�e veriAali�. /do JYenby cemjy aueder tbe paie�s� ofPa�+rry'that dte lwfor�r�ttoh pnovzdui oboae!s bxe awd enn+ert : �� f � �� o,lr� l>o . rr;uc name Phone# offidai ase a,ly do aat write Ia t�s aea te 6e os�piaed 6Y.dti or Mw4�eiai c�y�bwos ; pe�l6o�se 1! Depardmt ❑ehat i[i�mediale eeapsme is*�e4�� _ �s O�oe QHaMk De�ar�at ❑Of�r 1�� , ��'.