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Home My WebLink AboutApplication and WC � . .�.,S.So_t.4-� �P7�111.� " - - �" ► TOWN OF YARMOUTH BOARD OF HEALT, � i ''-=, ; � � APPLICATION FOR LICENSE/PF�VII. . i� /� r! �a„e o , . � �`�, .�� / . , / �� * Please com lete form and attach a11 necess �y �� ece ber 1 S Z010. � Failure to do so will result in the ret,�n o��t�i�-application p cket��L"t o�i P �� 3 ,�4 � ESTABLISHMENT NAIVIE:�• � TAX ID: — � - � LOCATION ADDRESS: ' --,; �- TEL.#: —3! 9' MAILING ADDRESS: t - �-, OVVNER NAME:-�t l ^ CORPORATION NA E F APPLICAB E): }►//R MANAGER'S NAME: - � " �r -'T TEL.#:._ �,�6 MAILING ADDRESS: �u `,. � POOL CERTffICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State la�v. Please list the designated P�o? 0��•�t�:•{s? a�� tta�l� a �•o�€�f t�ie certificati�?� to tlits f�r,71. 1. *� w ��.s E' � ��t� 2. Pool operators must list a mulimum of two employees cun ently certified'ui basic water safety, standard Fn•st Aid a�id Community Cardiopulmonaiy Resuscitation(CPR). Please list these em�loyees 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 �le at your place of business. 1. ' 'C� � N.S L.��CY'.�yT;- 1 '�Y fi 3. _ 4. � . _ � � . � �� - � -. � �� FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establisluilents are requued to have at least one full-time enlployee who is certified as a Food Protection Manager, as defuied 'ui the State Saiutary Code for Food Seivice Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must pro��ide new copies and maintain a file at 3�our establishment. 1. �� 2. PERSON IN CHARGE: EacIl fooci estauiisiunent must Iiave at least oue Person lii Cliar�e(FI�) on site duruig hours of operation. 1. � 2. HEIMLICH CERTffICATIONS: All food seivice establishments with 25 seats or more must have at least one employee trained ui the Heunlich Maneuver on the premises at all times. Please list your employees trauied in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide ne�v copies and maintain a �le at`�our place of business. 1. /��/'( 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER'VIIT?? LICENSE REQUIRED FEE PERI�IT� LICENSE REQLTIRED FEE PERVIIT� _B&.B S» CABIN S» ��OTEL S» _INN S55 _CAivIP S» I SR'I\�4ING POOL S80ea. �� _LODGE S» _ `TRAILER PARK S 10� ��-IIRLpOOL SROea. FOOD SER�'ICE: LICENSE REQL'IRED FEE PER�4II'# LICENSE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PERi�1IT# _0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 _>100 SEATS S160 CO':�LMON VIC. S60 ��IOLESALE S80 RETaII.SER�'ICE: —RESID.KIICHEN S30 LICENSE REQUIRED FEE PER�IIT?� LICENSE REQUIRED FEE PER�IIT~ LICENSE REQUIRED FEE PER'�IIT# ^<50 sq.tt. S50 >25,000 sq.ft. S?25 _VENDING-FOOD S3� _Q�,000sq.t�. S30 _FROZENDESSERT S40 TOBACCO S�i \��1E CHA�GE: sis AMOUNT DUE _ � 80: 00 ***�*PLEASE TLR�O�'ER A\ll CO�IPLETE OTHER SIDE OF FOR�T**�** � � .. 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 AF"FIDAVIT lYIUST BE COMPLE"TED AND SIGNED, OR CERT. OF INSU�ANCE ATTACHED Olt WORKER'S COMP. AFFIDAVIT SIC'7NED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to rene�val or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOT�+:I,S AND OTHER LODGING�STABLISHMENTS 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 use. 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 six(6)month period. Use of a guest unit as a residence or dwelling unit shall not 6e cc�nsidered 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 inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WATER TESTING: 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. POOY,Cr.USING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. 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,or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted 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 COOKING: _ _ _ _ Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND RE�QUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW E�UIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATF: � `,�/�� SIGNATURE: � r �� PRINT NAME&TITLE: ` t 1o�os io f i � � r � The Commonwealih ofMassachusetts • ' Deparhnent of Indust�zal Accidents NNf�'aNrr�l� h00 Washingto�Street, 7'"'Floor Boston,Mas� 02111 Workers'Compensatioe Insurance Afiidavit:gaildi�/pinmbieg/Ekctrical Contractors Anulit�at i.twrw��y Please PRIN'T k�M�► nacnc: �0 � �M�3 nQ.'C1 address_ -----f-'�'-��---��u-�f..� '� �----------.------------ �� s te: p� 7 zi hone �O — l"'Y�� d work site location(full addnss)• ❑ I am a homeowner pert'omnng all work myseif. Pro�ect Type: (]New Constniction(]Remodel ❑ I am a sole proprietor and have no one working tn any capacity. �gw�c�ng Addition �"I azn an employer providing workecs'compensation for my employees working on this job. _ _ ��l I,��' `(2r c� YLI.� _ �m�o��•_ , � c1..� ��.� �::�rz�� ,�,��"" addre�s• r�� n r J� �� --�s —lo+r{ i �jri: �,� �y��.�� r�l��,z�� o1wa�a �'''�`l! �,� 7 vS�Q Luoranceca M'I YYI pvW /A� l -�e�'� noL�^'# /-t--�� /� `�.,3.�� g�Q ❑ I am a so le � � � proprietor,geaeral coetractor,or homeo�vner(circ/t nn�)and have hired the contractors listed below who have the fo(lowing workers'compensation polices: COmD�HY O�l: �diEBs• citv D�09!� iH�OiSOC!t0. # COID1/�sY H�ID!' �f�!!!: CHY: D�O�liM .. _ . . . __....}� - .._.�-.. _ . .._.. .–_ .--.. _.-� ---- ------_.____ ._ __ _. _ . _ . _ _ _ _. ... .. . --�- - - . . _ ._. .. ... ��lR�'� # . . . 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