HomeMy WebLinkAboutApplication and WCi
- TOWN OF YARMOUTH BOARD OF HEALTH R�������
- APPLICATION FOR LICENSEfPERMIT-2017
*Please complete form and attach all necessary dceuments by r 6 016. NOV 2 3 z O�6
Failure to do so will result in the return of your applicatton pac et. �
ESTABLISHMENTNAME: vt �EPT.
LOCATTON ADDRESS: h 1 v'� TEL.#:
' MAILING ADDRESS: . . � vyro�
E-MAIL ADDRESS: 1�15 ww'Iz 4J�.v C
OWNER NAME: �� 1 S'i,�l S' a�^t �7 r LL
CORPORATION NAMEQ�APPLICABLE :
MANAGER'S NAME• �L���(�l �� ��w��'`h . TEL.#: �
MAII�ING ADDRESS: '0� '1 v S a.!�c�I► w�Q- G2G Y
POOL CERTIFICATIONS:
The pool supervisor must be certified as x Pool Opcmtor,ss required by State Iaw. Please list the designated
Pool Operator(s)and attach a eopy of the certification to this form. � ,q;>�;,,;�
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1.__Jf�t IZ V�'t �G b( S 2. ,
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Pool operators must list a minimum of two empioyees currendy certified in standard First Aid and Community
Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the � -
employees below and attach copies of their certifications to this form.T6e Health Department will not nse past �'
years'records. Yon must prnvide new rnpies snd maiatain a file at your place of bqsinesa. -- rS'''
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FOOD PROTECTlON MANAGERS-CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protecrion 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 pxst years'resords.
You must provide aew eopies xnd maiutaio A ftie at your estxblishment.
I- 2.
PERSON IN CHARGE:
Each food establislunent must have at least one Person In Charge(PIC)on site during hours of operation.
1. 2,
ALLERGEN CERTffICATTONS:
All food service establishments are requized to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(Gx3xa). Please attach
copies of certification to this applicarion. The Heaith Department will not use pAst yenrs'records. You must
provide new copies and maietain a t'ile at your eatablishment.
i. 2,
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more mast have at least one eraployee trained in the Heimlich
Maneuver on the premises at atl times. Piease list your employces trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Nealt6 Dep�rtment will not use past years'recorda.
Yoa mnat provide new copiea xnd maintain a fde at yanr plaee of bnsiness,
1. 2.
3. 4
RESTAURANT SEATING: TOTAL#
t301�L-1 S-��2(-02
toncnvc:
OFFICE USE ONLY (o) BpktSQ_15�(12Z.��„
LICENSE REQUIREp FEE PERMIT# LICENSE REQUIRED FEE PERMIT q L CENSE REQUIRED FEE PE ��IT.N.���
�8 SSS CA9IN S55 �M07EL 5110 '��'"'"""��
--�D�E S55 �SWIMMING POOL SI l0ea.
SSS _-7'RAILER PAWC 5105 WHIRLPOOL S110ea
FOpD SERVICE:
LICENSE RE UIRED FEE PERMIT# LICENSE REQUIRF,D FEE PERMIT# LICENSE REQ UIRED FEE PERMIT#
—��S�� S2� _CONI'INENTAL S33 NON-PROPIT S30
— ,COMMON V1C. S60 —WFIOLESALE S80
RETAILSERV(CE: —RESID.KITCHEN S$0
LICENSE REQUIRED FEE PERMIT# LICENS£REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<<SOsq�R SSO >25,000 R S285 VENDING-FOOD S25
<25,�0 sq.ft S150 �ROZEN�ESSERT S40 �I'OBACCO 5110
NAMECHANGE: Si5 AMOUNT DUE = S 220„O�
*"*"*FLEASE TURI+i OVER AND COMPLETE OTHER 3IpE OF FORM•••""
e
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' ADMINISTRATION
Under Chapter 152,Secrioa 25C,Subsection 6,the Town of Yarmouth is now required to hold iss�ance or renewal
of any license or pexmit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACIiED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLEI'ED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal oc issuance of you.r pern�its. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTI�R LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transicnt occupancy sha((be
limited to the temporary and short term occupancy,ordinarity and customarily associated with motel and hote!use.
Traasient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient occupancy shall generaily refer to condnuous occupancy of not more than thirty(30)days,and
an aggregate of not more than ninety(90)days witlun 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 Occu�ncy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient.
POOLS
POOL OPENIlVG:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Deparhnent pnor to opening. Contact the HealthI)ep ent to schedule the inapection three(3)
daya prior to opening.��ASE NOT'E:People are NOT allowed�t in the pool area until thc poaI has been
inspected and opened.
POOL WATER TESTING: T'he 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 quarteriy
thereafter.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASO1vAL FOOD SERVICE OPEMNG:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the '
Health Department to schedule the inspect�on three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yazmouth mast notify the Xarmouth Health Department by filing tbe
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 CAF�.S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is gro6ibited.
NOTICE:Permits ruu annually from January i to December 31. iT IS YOUR RESPONSIBILII'Y TO RETiJRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. .
' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
� EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I
TO COMMENCEMENT. RENOVATIONS MAY IjEQUIRE A SITE PLAI�i.
DATE: ��G 7^� y SIGNATURE: `�
PRINT NAME 8c TTTLE: ,S��`1d�`/� �i Gi��' �°""'`L
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f�'�"'"'� SKP1M-1 QF�1D:MK
'`����� GEF�TlFICAT�"t]F L#ABtLITY INSURANC� Qs�Qp'�"'
'iHiS CERTIFICATE IS 13SUED AS A MATTER AF tN�QRMATION ONLY AND CONFERS N4 RIGHTS UPQN TtiE CERTfFICATE HOLDER.THlS
� CERTIFlCATE DOES NQT AFFIRMATiVEI.Y OR NEGATIVEi_Y AAA�IQ. EXTEt+t[?OR Al'fEii TH� COVERAG�AFFQRDEO SY THE AOLiCl�S
�.UW. THIS CERTiFiGATE OF INSURANGE DOES N4T CONSTlTUTE A CONi'RAC7 BETWE�PI 'i'tiE ISSUlNG tNSUR�R(S�� AUTHORf�D
REPt2�SENTATIVE OR PRtMUCER,ANQ THE CERTIFlCATE IiOi.DER
MAPORTANT: tf tfie csrNficate holder is�ADOf17QNAt IMSURFA.the poticy(ies}m�t be sndwsed. if 8t1BRQG�►TiQT�i IS WANEQ,subje�t to
iF�e temes and condFH�of U�e potfcy.certa�poficies may raquire an endorsemeM. A statemertt on dtis ceKificate daes not confer rights�the
ce�f�ts hofder in tieu of such s.
�irisurance AgenaYY,� eur�T DGP-Mi1es Insurance A ,Inc.
3 SchooF Street P.O.Box l018 508-824-8961 ,508-880�734
Taurttan,MA 02780-0967 �: .
C3wdon G.Asack
A�FO�t:O�AGE ' t�A
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msur�u SKP7N1�LLC dba Skippy's P�r i
�31 Main Streei,U.0 a16a �u�t s•
Tavem T31, 277 S.Shore Qr* ��c:
L.LC dba Swfi�Sand INc�tet a�u: -
Sandra Di C3iovanni
P.O.Bo�c 370 ���:
S Ya M�102684 �F;
�OYERAGE3 CERT�lCATE NUMBER: _ REViSWN Nt�IiBER:
THIS IS,TO CERTIFY THAT THE POUCFES OF INSURANCE LtS'fED BEL�3W tWYE BEEH ISSUED TO THE INSUREO NAMED A�VE F�t THE F�OUCY PERKN?
INOtCATED. NOTiMTHSTANDING AFIY REQUIRE#IENT.TERM QR CONDITIOIV OF ANY CONTRAC'f OR OTHER Df3CUMEN'f'WITH RESPECT TQ SNFiICH TtqS
CERTIFIGA'i'E MAY BE iSSUEO QR MAY PERTA�f, THE INSURANCE AFFORDED SY THE POliC1ES DESCWBE� HERENJ tS SUSJEC7 70 AlL THE TERM3,
EXCIUStONS AND CONDI'FIONS OF SUCN POLICIES.UNRTS SFIOWN 14fAY NAY�BEEN ftEOUGED BY PA1D CIAfMS.
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