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Home My WebLink AboutApplication and WC TOWN OF YARMOUTI�BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by D�ecember l6 2016. Failure to do so will result in the return of your applicahon pac et. ESTABLISHMENT NAME: vv .-�.. x�� LOCATION ADDRESS: ca� �G.. �t�MO• L. : .�C� G� f,� MAILING ADDRESS: o C�` � o a r E-1VIAIL ADDRESS: " T r'�"�i ,C�G owr�RN.�: � , �. �+�r� � CORPORATION N APRL1C LE : ' ��, ��► v� � MANAGER'S NAMEA��JG�4. � � L. : O . � I �� MAILING ADDRESS: d o o r r�u� cv�G POOL CER'TIFICATIONS: The poal supervisor mast be certified as a Pool�perator,as required by State law. Please list the designated Pool Qperator(s)�d attach�eo�the certifi 'o w tlris form. �" i. M ��li`4�\ 4 c� � z. = o � Pool operators must list a minunum of two empioyees currenfly certified in standard First Aid and Community � �' n Cardiopulmonary Resuseitation{CPR),having one certified employee an premises at all rimes. Please list the � _.: �,� employees below and attach copies of their certifications to this form.The Health Department will not nse paat -•- �,,� years'r�ord You mnst provide new co ies and maintsin a file at yo,�r place of business. �.7 N ��;" i °'?? �'a�.�. K i. �. � qc�� i a. 1 ��c�� --i o, � 3. 4. FOOD PROTEGTION MANAGEILS-CERTIFICATIONS: All food service establishments are required to have at least one full-time emptoyee who is certified as a Food Protection Manager,as defined in the State Sanitary Code for Food Service EstabIishments, 105 CMR 590.0(Kl. Please aitach copies of certification to this application The Healt6 Dep�rtment will not use pa�t years'records. You mast provide new copies and mai�tain a file at your t�tablishment. o-y� 1. 2. ' � PERSON IN CHARGE: Each food establishment must have at least one Person In Chatge(PIC)on site during hours of aperation. �� 1 2. �:� ALLERGEN CERTIFICATIONS: —� All food service establishments are required 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 59t?.Ot?9{Gx3)(a). Ptease attach A,_� copies of certification to this application. T6e Health Department will not nse past years'records. You mnst provide new copi�and e��intaia a file at yonr establishment 1. 2. ' HEIMLICH CERTIFiCATIONS: • Ati food service establishments with 25 seats or more must have at least one employee hained iu the Heimlich Maneuver on the premises at all times. Please list your enployees ttained in anti-chokmg procedures below and attach copies of employce certifications to this form The Health Departmeat wlll not nae past years'records. You must provide new copies and maintain�file at yonr ptace af business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# O�FICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMC!'# LICEN3E REQUIRED FEE PERMIT# CENSE REQUIItED FEE P q �B S53 CABIN S55 �M01EL S1)0 ,}, A�1N S35 CAMP SSS SWIMMINGPOOLS110ea-��'f'S =1ADGE S55 �1RAILER PARK $]OS �WHIRI,POOL SI IOea FOOD SERYICE: LICEN3E REQUIRED FEE PERMPI'# L ENS6 REQUIRED FEE P T#Q LICENSE RE UIRED FEE PERMIT# a�1 SEATS 5200 �COMbipNrVIC $60 "' - ' — ``� �VI OLES�ALE S80 RETAII,SERVICE: —RESID.KITCHEN SSO LtCENSE REQUIItED FEE PERMiT# LICENSE REQUiRED FEE PERMIT# LICENSE REQLIRED FEE PERMIT ll �SOsq�ft. $50 >25,000sq!t 5285 VENDING-FOOD S25 =<25,OOOsq.ft $I50 =FROZENDESSERT S44 =7'OBACCO SI10 NAME CHANGB: a�s AMOUNT DUE = S a-SS.DC� •••••pLEASE TURN OVER AND COMPLETE O'CHER SmE OF FORM••••a V Q{a'(..^�5•{(J U!�Z C��6o#s�-t5-l�o8-�6Z �0��0 1—� ADMIMSTRATION Under Chapter 152,Section 25C,Sabsection 6,the Town of Yarmoutb is now required to hold issuence or renewal of any(icense or permit to operate a business if a person or company does not liave a Certificate of Wo�ker's Compensation Insurance. THE ATTACI�D STATE WORKER'S COMI'ENSA'i'ION INSURANGE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED � OR WORKER'S COMP.,AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and tiens must be paid prior to renewal or issuance of your petmits. PLEASE CHECK APPROPRIATELY IF PAID: YES�_ NO MOTELS AND OTAER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotal use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hatel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shalt generally iefer to cvntinuovs occupancy of not more than thiriy(30)8ays,and an aggregate of not more than ninety(90}days within any six(�month period. Use of a guest unit as a residenoe or dwelling unit shall not be considered transient. Occupancy that is subj�t to the collection of Room Occupancy �xcise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPENING:AIl swimming,wading aud whirlpools which have bec.m closed for the season must be inspected by the Health llepartrnent prior to openu�g. Contact the Health Department to schedule the inspectian three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area unfil t�he pool k�as been inspected and opened. POOL WATER TESTIlVG: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab,and submitted w the Health Department thrae(3}days prior to o�ning,and quarterly thereafter. . PflOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENII�IG: All food service establishments must be inspected by the Health Department prior to openi�g. Please contact the Health Departmem to schedule the inspection ttuee(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Degartment,or from the Town's website at www.varmauth.ma.us.under Health DepaRment, Downloadable Forms. FROZEN DESSERTS: _ Frozen desserts must be tested by a State certified lab prior to opening and monthly thereaftsr,with semple 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 tem�s have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waitez/waitress service),must have prior approval from the Board of Health. j OVfDOOR COOKING: Qutdoor cooking,prepararion,or display of any food product by a retail or food service estabiishment is prohibited. i � � NOTICE:Permitc run annualiy from January 1 to December 31. 1T LS YOUR RESPONSIBILTTY TO RETURN , 'TI�COMI'LETED RENEWAL APPLICATION(S)AND REQiJIRED FEE(S)BY DECEMBER 16,2016. ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMEN"I',ETC.},MUST BE REPORTED TO AND APPROVED BY THB BOARD OF I�IEALTH PRIOR j TO CO�NCEMENT. RENOVATIONS MAY REQ TE P'LAN. DATE: I oC� O—' ��o SIGNATURE: { �PRINT NAME&TITI.E: i , ' q �i � t�.►aiuie A s�t� Hat�away c,vaRu s�Be rksh i re H ath awa R o. Box A-H• f6 S. i�rer S'te+eet �1,� Y WiNces-Barr�,PA 187Q3-0020 �:. G U A RD Companies 57�825-99�0{ToN-F��80Q-687�2�5g www.guard.com 05/iQ/2416 Shooshab Inc PO Box 1054 ' South Yarmouth, MA 02654 Notice of Poli+cy Renewal Po� Iwnnber. SHWC760734 Poi-ic�/ Period: QS/22J2015 - 05/22/2017 Total Estimated Cos� $ 604 Payntet�t Method: t�IRD i�port�g Lrt,erface for Pa�/ro� Raymerrt Ter�ns: Paym� Deduction 1 Berkshi� Hathaway CUARD I�urance Companies has recentiy r�enewed your Worlcers' � Compensatan and Emptoyers Liabi�y Insunnce coverage far the term indicated above. Since payment for this account is being handfed through C�iARD's R,eporting InterFace for Fayrott ((�2IP�, your pr+emium w� be paid in instal�nents that carrespond to your payr+oN cycle. The firm that handles yau processeg w�teY us when to debit the bank account yau spec�`ied. Upon rece�it of that notiP'�cation and at least 24�ours prior to the trartsaction, we wiN fax or e-ma�a Direct L)raft A�tace, indicating the arrount and_the date of the transfer. If you have any questio�, piease feel fr+ee to contact our Cr►s�omer9ervice D�p�artment at 8�0-673-2465, or via e-ma�at csr�tlARD.com. Thank you for daing business with Berkshire Hathaway t�1ARD Insura�ce Companies. We bok fo�nrar+d to serving you for another year. E►9ency: CUMPUPAY INSURANCE SERVICES., INC. 14Q1 Forum Way _ Su�e 5Q0 ' West Pa�n Beach, F�33401 Phone 800-807-0598 Fax 305-675-8141 ' c�t�te,�w-ea o�-ae