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Home My WebLink AboutApplication 5I5I�'7�« P o.e.Ka�Q d, c-�n.p s� �oa. c�-Q a,.., c a n 0.y� S vat a.l...a.�ar O/1� , TOWN OF YARMOUTH BOARD OF HEALTH L, J\�, ,,�;�� ' � APPLICATION FOR LICENSEfPERMIT-2017 v "`' *Piease complete form and attach all necessary documents by December 16.2016. �'1t,Y u � C01� Failure to do so will result in the return of yow applicaUon p'acicet. ESTABLISHIbIENTNAME: V HEALTH DC�1. �p2. d� LOCATION ADDRESS; 01 TEL.#: �� ,�- MAILING ADDRES ; VO SO X SQ 8 S 'fle,nn.c M A O:L 66� E-MAII.ADDRESS: OWNER NAME: 'n`11f B A CORPORATION Nt�ME(IF APPLICABLE): MANAGER'S NAME: �.sv,,, Cohde, TEL.#: 617 43 5 q�t3� MAILINGADDRESS: 3\ I�arc•• Ave. S. 'Dcn..,s MA d�►66c> POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as reqnired 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 minunum of two employees currently 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 tlus form.The Health Deparhment will not use past years'records. Yon must provide new copies and maintain a file at yonr place of bnsiness. L 2. 3. 4. FOOD PROTECTION MANAGERS-CER'TIFICATIONS: 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 of certification to this application. The Health Department will not nse past years'records. You mnst pmvide new copies and maintain a fik at yonr establishment 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Pecson In Charge(PIC)on site during hours of operation. 1. 2- ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fiill-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 application. The Heatth Depsrtment will not ase past yesrs'records. Yon mast provide new copies and mamtain a fik at your establishmen� 1. 2• HEIIvILICH CER"I'IFICATIONS: 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 t�sined in anti-chokuig procedures below and attach copies of employee certifications to this form. The Health Deparbment will not nse past years'reeords. Yoa mast provide new rnpies and maintain a Sle at your place of bnsiness. 1. 2• 3. 4. RESTAURANT SEATII�TG: TOTAL# OFFICE USE QNLY LODGING: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PIItMIT# LICfiNSE REQUIliID FEE PIIZMIT# B&B S55 CABIN S55 MOTEL 5110 �TNN S55 CAMP S55 _SWAI1vIIl1GPOOLS110ea LODCrE S55 TRAII.ERPARK S10S _WHIRLPOOL SllOea. FOOD SERVICE: LICENSE REQUIRED FEE PERT�llT# LICIIJSE REQUIItED FEE PERNIIT# LICENSE RF.QUIItID FEE PERNIIT# 0-100 SEATS 5125 _CONTINENTAL S35 NON PRO�rr aso —>I00 SEATS 5200 _COMMON VIC. S60 —WHOLESALE S80 — �RESID.I�1T'CfIQd S80 RETAIL SEItVICE: LICENSE REQTJIRID FEE PERMIT# LICIIVSE REQiJlRED FEE PIItivIIT# LICENSE REQUIRID FEE PF121uIlT# <SOsq.ft. S50 >25,000sqR. S285 VENDING-FOOD S25 -QS,OOOsq.ft. $150 _FROZENDESSERT S40 _TOBACCO 5110 rrn�c�uvice: ais AMOiJNT DUE _ $ +�;**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�+�''* P� �� - w��v�D �- -�wic.c.oNl.yNr..�D �'�*'��r �F CfRcu.s�cTc. i►� Ftl�. . ' ADMINISTRATION Under Chapter 152,Section 25C,Subs�tion 6,the Town of Yarmouth is now required to hold issuance or renewai 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 taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISffi1�NTS TRANSIENT OCCUPANCY: For piuposes of the limitations of Motel o�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 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 shall 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. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed far the season must be inspected by the Health Department prior to opening. Contact the Health DepaRment to schedule the inspection three(3) days prior to opening.PI.EASE NOTE:People are NOT allowed to sit in 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 couttt by a State certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPE1vING: All food service estabiishments must be inspected by the Health Department prior to opening. Please contact the Health Depanc�►ent to schedule the inspecrion 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 requu�ed Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.varmouth.maus under Health Department, Downloadable Foims. FROZEN DESSERTS: Frozen desserts must be test�l by a State certified lab prior to opening and monthly thereatter,with sample results submitted to the Health Department. Failure to do so wiil result in the suspension or revocation of yow 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 appmvai from the Board of Health. OUTDOOR COOKiNG: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibibal. NOTICE:Permits run annually from January 1 to December 31. IT LS YOUR RESPONSIBII.FTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISI�IlVIEEIVT, MOTEL OR POOL (i.e., PAINT'ING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMI��NCEMENT. RENOVA"i'IONS MAY REQUIItE A SITE PI.AN. DATE: 5�S�J 7 SIGNATURE• __„� PRINT NAME&TITLE: .�o an C e+�►a.n � E�re s�a�Qn-� x�.ia�vie