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HomeMy WebLinkAboutApplication and WC �-� TOWN OF'YARiVIOUTf[ 130ARD OF�IEALTH ����� APPLIGAT1011 �'OR LIC'ENSF/PERMI'T-2U13 � "''�,� ;: Please�:�.omplete.form �nd attach ali necessaiy docui»ents by December 1�,20U. }':�ilure rt�do so will result�in thc�return of your applicalion�ackei. EST��f31�IS11'�11:;N"1 NAN1E: • �c `' -i.TA.l [D: .� ���� L,OC';�T'IC)P;ADDItLiSS:�. _"1 GL.#k:�j3�-c�7,-'�t/ N1AtI,1NCi A[jDRLSS: a5_�'r,� +�� �`.,� d��?�i ------ L-IvIAII �l�DRFSS: ` � ` h.v_f' k oM�__ _....-- -- - � �;., OW;vER N;1?�4L����� � s Zn�, ;i� p � , ��� ---� — CORPORA�TIO'V NAML�('TP APPI.,C��III,1��):_�"�fZ��-�����5.� C,..,_ �' •C . NIA^�ACiL-'R'S NANIL-;:�(��-M��,I�`Yt)v�ti,. 1��5����„°�`TF,L.#: �''� `���"'��� �� C? � j � ��� MAILINCi tiI�DR1:.SS:��_�,gj�{ �g�{'�,b}� � � � -� � � �� � F'.,+� PUO[.CERTI�ICA"1'IONS: � The pool si.ipervisor must be certitiecl as a Pool Operator,as��equired hy State law. P lease list the designated ~ ���'� Pool Opeiat�r(s)and attach a cepy ot"the certification to this f'orrn. � ''- r`� `�t , � ( --�_.._...�_..�; l._ ?Tti:Y'.Yl�������--- _ � A' �t' �-�,d2i',i�.l Puol operators must list�i minimum of t���o emPloyees currendy certilied in st�jnd�u�d F'irst Aid and Community C:ardiopulmonai•y Resascitation (CPR), having one certifietl employee on premises a< <ill ti�nes. Please list thc - employ�cs belo�v and attacl�eopies uf tl�eir certitications to tliis form.The Health llepariment will uot use past ��cars' recorcls. You mnst provide new copies and maintain a tile,�t your place of business. n /J i� 1. �J�`tm-�a.. �..� 2. � O'r.c`J�' � ., �c'. —�-- ��--- -- i.�-1���` 'Pt.� _ 4. `�,_— — .o�_..� ��-�� � FOOD PR(f I'1�C_I IU�I MANAGF�F'.5 C l R1IFICA"CIONS: �-��"� r\ll Iood seivice establishil�ents �ue iequ��ed to have at least onz lull-time employee ���h.� is ceitifi�d as a Food ,� Protect«n `.�ana��er, as delin�d in the State Sanitary Code tor Food Service Establishments, 105 CMR �90.000. 1'lease attac�z cop�zs of ceilification to thi;applic�rtion. The Hea)titi Department wi!Il not use pastyears'records. �� Yau must pruvide new copies and maintain x file at yuu►•establisliment. ,Y;', �. �r��� �u��i�— ��-- - — � PERSON I�N C(-IAP�GL: Each f��od est�blishment must have at leasi one Person tn Charge(I'IC)on site during hoius of operation. I.�fY�+.-r�-ts- vt� � �,/*�— �• -- -- ALI.,F,RGF_.N i_:F.,R"1�[['fCA1�I�JNS: All tood service ests�blishments are reytiiir�d to have at teast une full-t�inle eiuployee wl�o has Aller�?en cer�itication, as detined i�i ttie Stati Sa��itarc�Co�le fiar F�iod Service Establislmlents, 10�CVllt.590.004(Gj(�)(al. Please��ttach copies of cci ii fication to this<ippfication. The Ficalth Department���ill n�t use p.ast}�ears' records. You must provide ne��tiopies ancl maintain a file at your establishme�it. 1. ��n.w�. ��1,1��aN�- �- _- — HEIMI,tCF-i CERTIP[CA'TIONS: All fooa service esYablishments witli 25 seats or more must I�ave at least one emFloyc;e trained in the Heinilich �laneuver on f6e premises at all tinu�s. Please iist yow�employees trained in anti-cliokin<_procedw�es belo�,v and attach copies of employee cert�iticatiims to Chis i�orm. The Iieatth 1�3eE>artmci�t will n:�t use past yeai•s' records. You must pravicic new copies and �nai��t�in a f'ile at y��ur place of business. i,�rru�. J:1.��t'�4X-- � �._ —a:- ---- R�ST'Al?RA'�T SLf�"I'Ii�'G: TOTnI,# . OFI�:CCx USE ONLY r� i iciixi r.ai: uih��,i� 5�.': i i ii�u r�- �-i<<�t�i;rtr �i�:i:n S„ �c�,r�nr„ �ic�h��klclini t�� �a�F i r.�- r� �Ci�L-�y-'�b�t2 � ��•inc: `' �- " ° ���o —003 _o� _......_ 1.htc>IeL. IV'J • - -- �.ti6\1\1�41NG t OOt.�l I��a _QC��QS _�_oncr: �>; __ ir�,ui_i:a�,ar.ti s�i��� - � .��;Firtii,N�aoi. siioz�,. � <<��ol4SP-��f-ob4y f O011 SFR�(CE: t I(I:NSP.RE�UIRF.D 1=CI3 Pf-.RVII'f� IJ(1 T�1Sf ftEQUIRED 1-L•G YHR\4I"I'y I:ICfr.N56 R6QU[[�F:D FlL PHRVII'f?? �'0� l._��-�oo5rar5 SI?5 ��!Q��} '_ (0�1'I!�'PNI'.Al. Sii —�`vivlRUFI'f $30 ----- >!00 tiC';>I'S fi?q0 '�_COR9MC)N VIC. S(i0 ����. V�I101 f��AI T 530 q iir i �i►.s�r�u c. -- r,t sin F:rrc E�c� 5so ----- (�)L3o�SP'1�( bobNb �i�i ti�i;i r,,i.n.i:i� r r:r r�ri �i�i = i..ic i�;,i ui c1� u i;r� i r i, i�r.rniir;; i ici.h�F ar oi �hf r� rt:i Pr,riw i :, I ;o:q fi � p �1 i� ��(li)0 sq It S�S? �ht[)I\:�-F OOD SZ� �WP�00�—�t(���f �>UUO:q Il:. - __ -- �--- ���l 3I�(i __ _ _tLOZF.tiDFSSI.R'I Sd0 _— -- _...'IOli,\�:Ci> �,IIU ---- -- �,�;�tccttn�cF:: Si� --- =�MOLNT��UG =° � (e T��O� _-- �p1�4F•IK��f-0-04 ^,*'rt"I'Lf•,AtiG 1'Ut�\O�'EI't AYU COM1tPLGTE O"1'NI�;R SII?F:OF�01217::;°''^ � AUMINISTRATIC)N � Under Chapter 152.Section�'.�C,Sub�ection 6,the'To���n�ofl'armouth is nuw required to l��oid issuaoc�or rene.wal oi'any license or pennit to orerate a busine;ss if a pers�n or company daes not have a Certiticate ot Worket's Com}�ensation Insurance. 'Cr-1G ,AT'CACH�D STATE WOlZKEK'S COMPI?NSATION INStiR,�.NCT AFI�IDAVIT Mt1ST BE COIviPLI?TED?�NU SIGNLI},OR CE�fZT.OF INSUP.i�,NC'E�.<1"I'��nCH}�.D�. OK WORKER'S COMP.AF�'I•'IDAViT�SIGNED:�ND AT'i'AC11:ED___ l'o�-vn of Y"ailnouth taxes and liens must be p�id prior to rene�val or issuance ol�your pei7nits. YLGAS.F,CI-IF,CK APPROYF:IATIiI,Y IF PAII>: YFS ' NO __.__ MC►TELS AND OTNLR LODGING T:STAI3i,ISHMI:NTS TRANSITN7'OCCUPAN(�Y: Por pui�>oses of the limitations of Motel or Hotel use,Transient accuUancy shall be limited to the teinparary c3nd short term occupa�lcy,ordinarily ancl customarily assoc,iated with motel and hotel use. "I�ransient occupants rnust l.ave a3id he aUle to demonscrate that the�� �uainta'rn a principal place of residence else�.vhere.l ransienr occup�ncy shail��enerally ref'er to continuous occupanc}-ot not more lilan thirry(30)day�s,and aii ag�re�,ate af not more thail niti�ty(9b)da.s�;�ithin an��si�(6}month perioci. Use of a gucst unit 1s a residence or dwelling i.init shall not be considered u�ansient. Occupancy that is tiubject to the collection of I�oom Occupancy l:xeise.as defined in M.G.I...c. 64Ci or 830 Cti'IR 64G.as amended,shalt�ener�lly be considered (1'ansi�nt. POOLS P()OL OPI:NING:AI1 swimmin�,wacting 1nd whirlpoc>Is which l�ave becn closed for tlie season must be insp�cted bv the Health Department prior lo opening. Cc�ntact the 1-lealth Departitient te schedule the ins��ection three(3) days prior to opening.PLf?ASF NOTE:People are NOT allo�ved t�o si[in the pool area until tlie Pool has been itispected and opened. POOL W'.4T1sP T�S7'�t�'G: The water must l�e teste�for pseudomonas,total culiforni and standard plat�counC b�- � State certified lab, anc submit�tecE to the F�Iealth De�.�artment tliree (3) ��ays �prior to opening, and quarterly thereafter. POOL Cl�OS1NG:Every outdoor in�round sv.-icnming pool must be drained oi•covered�vithin seven(7)clays of closina. FOOD SF,RV[C� SCAS0�.�1L FOOD SER��'ICG OYL;NING: 11l foo�service establishmc;nts must be inspected by the Health Depzu�tmcnt prior to opening. Please contacC the Heatth Depairtment to scl�edule tl�e ins�iection three(3�)days prior to openin�?. � CATE121�iG POL[CY: Anyone who catcrs �vithin dle "l�own of Yairo�ouih must notily the Yarmouth }Iealth :Jepartment by liling the requu•ed 'l�cmpo�ary Food ,�ervice Application form 7' hotu•s prior to th� c�iterecl e��ent. Thesc forms can be obtained�t the Health C)c��a:Cment,�r h•om tlie"To��n's website at�vww�armouth_na.us under f-iealthDeparhnent. Dotivnloadable Porms. FR07F.�v QI:SSGRTS: Frc>ren desser[s must be tested by a State certiiied]ab prior to opening and monthlv tl�ere�d:ter,with sample results sut>mitled ro the Heaitl� Department. Faihn-e to do so will resi.�lt in the suspension or revocation of y�ow�Frozen Dessert Permit until the above t�rms have heen met. OLiTSlI3�CArES: Outside c<�fes{i.e.,outdoor seating�vith waiterl�•'aitress ser�>ice),must have prior a��pro�-'al ti-orn the Board oF Health. OU7'D0012 CO�KING: Outdoor cooking;preparation,or display of any tbod product by a retai.l or fi�od ser�%ice est:ablishment is prohibitect. !�'nT[CE:Yerinits run anniial ly frotn.lanuary 1 to December 3 L [T IS YOUK 1ZESPONSISILITY TO RETLIRN `CHE COMPL.GTEi>RF.,NE'.WAL.�1P�PLICA'I'ION(Sj AND I��QUIRCD PEE(S)F3Y D�CL:A�[BER 1�,2017. :aLL KENOVATIONS TO ANY I�OOD GSTA:Bi.1Si-TMCN'C, '�lO�1EL OR YOOC. (i.e., 1'Al'1V`7'1NG, NEW I;QUIPMf�,TJ T,L"['C.).MUS7'CiF..RF..,POP.'TF..I)TO AND APPROV"F.D B5`" HI:I30.�1I:D OF IILALI'H PI:1OR TO COI�II�qENCL:MI>N�C'. RF;NOVATIUNS Mr1Y RLQIJI. :. ; L. � D�'�TE:�j : � ; � _ S1GNA"l�Uhl_,: _ ' YRIPJT NAMF.,�TITI,F..: . ��v!��- - ��— - - {-- r.,, in;rz;i-; A�C"�a onra�.cr�u-�� ,..._..___.��F�� �..-�-- ���T���car� c�� �r����.�T�r{�su���� = n��E��a�,��� . ,_------d-___�__._ __.,__...�.,�.....�. � 4d11i t2k�47 __...__.._ _,__...�___�----------__ { . _..__,_.._�.___.......�___.__.. ...�.__.� HIS CER7TF#CA7E 16 FSStJEB AS A t�AliTT�F� OP lkPtlitMS4?#QD7 Rtit.Y AN�G�}htF�RS tdt3 Ri6MtYS UisGt#�FHE CERTffIGAfi�N13Lt?ER.TKd�u� - i i GERFfFtGATE t5C7�$ Nt?T AFF`[RMf1TdSt�L'Y {3�'t�4�GAY7'StELY i4#�ht�3, EX7EIdf7 pR Tt�TEFt TH� 6t3V�if'tAC�E APF�F2d7E6 BY TNE PC3LFGIES : BEi.OW. 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