The URL can be used to link to this page

Home My WebLink AboutApplicationI _. -- -- - ---- --- 1 .. TOWN OF YARMOUTH BOARD OF HEALTH .4.--------- s'i71- N-,74:_ . APPLICATION FOR LICENSE/PER6HT-2019 *Please complete form and attach all necessary documents by December15 2018. NOM ALL B WITHLI 0 LICRAMUMUSTRATURNFORla SY AVVEMBER 15*. Failure to do so will result mihe return of your application packet ,----N ESTABLISBMENr NANIE:C.ova_.%ecA,Ss 1-kr) c- TAX ID: LOCATION ADDRESS:3•1,-)... i\ooie tov. TELAso si‘-3LD MAILING ADDRESS: 01E. E-MAIL ADDRESS: (4 Nrcto 9...1\g-.1) CO WI pi as 5 t\.ck.SC.C.-ciii)ecoli...CC.AA OWNER NAME: CORPORATION NAME(IF APPLICABLE): CO•.(vx QPtss cz.0%-e 1--lose.VcA0•4---}-Doc- , MANAGER'S NAME: MLR: t ____ MAILING ADDRESS: s...\p„of T ---a---- 2 POOL CERTIFICATIO iz: • ,.,,:.: The pool supervisor . •-, , -certified as a Pool Operator,as required , •State law. Please list the designated Pool Operatra(s)and attach- - copy°hire certification to this form. '.- X --.1 1=3_ 1. 2. 0 Na mcp Fg Pool opetators nmst list a min' im t, , two employees currently certified in ,,,,,..,,.. First Aid and Commtmity Carthopuhnonary Resuscitation(CP.' having one certified employee onpremises . all times. Please list the employees below and attach copies of*,.-. certifications to this form.The Healthi - ,,- twill not use past years'records. You must provide new ..•,J - and nraintson a fiie as yaw Owe ,, i ..,*,. _.• ANIM...........10•11.01•1•170•011•01 1. Z. 3. 4 14 ,,ATII 14, - FOMPROIECTIONAWWW2S-CEMECAPOW All food service establishments are required to have 3 least one full-time employee who is certified as a Food ,.. Protection Athmager,as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.000. "Please attach cope:"s ofcertifxafion to this application.The Head&Departmentwal sot use pastyears'stands. You must provide new copier-mud maintain a file at your establishment. • 1. 2. qg PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Pv•i•-)6...641.49... ictA)A.A.1-\--dv,. 2. ' g: t730 ALLERGEN CERTIFICATIO : ' -- •T= Ali food service establishments,-aspired to have idleast one I, i,.,,-employee who has Mager'certification, Ti) r ‘ i as defined in the State Sanitary .,• fix Food Service Establisbments 05 CMR590.009(0)(3Xa). Please attach :i copies of cafifiatkarto this,,,.,r - Tbe Health Department :! , • use past yaws'records. You newt — provide new copies and maiutnn' a ii . at your establishment. j 1 -P. _.c. 2. ....) ._.) 1. CO 6"‘ BEIMLICH CERTIFICATIONS: cb Allfi3od service establishments with 25 seats or ,• .- - artist have at least one -,,,,,%',•- brined in the Heimlich Maneuver on the premises at all times. Please list -. , employees trained in-•,,r ,•,*,4,,-1.procedures below and ! attach copies ofemployee certifications to this form. 4'•, Health will ,• use past years'records. You must provide new copies and maintain a file at ,, • place OIbUSIUCSs. RECVU 1. 2. 4. —Rev 2 7 2018 - . RESTAURANT SEATDIG: TOTAL# \ , -- LKENEELoaGiNeEEQUIEED FEE Fuear#41(tiaoulcENEEOFFIREQuou3DCE US:EON:EL# umsEEEQuEtED FEE ..."11C.ni‘FEEmn. 1:71.-1 '777 B&B S55 MMEL $110 it s INN $55 GE mi _ CAMP ngairy _CABIN 555 $55 SWIMMINGPOOL$110es.--____ I --7-1•MS55 'TRAILER PARK $105 FOODSERVIegt LICrioTREENIBED sFEEs PERMIT. LICENSEREQUIRED FEE PRIRMVT. LICENSEIFEE PERMIT# _NO/iPPRVR")$30 BMA SIOLVKZ: —RESIGIGTCIEIEN SRO ----- UCENSEREQUIRED ME PERMIT. uaisaEREQuiRED FEE pERkirr# LicF2,4EREQuEtED FEE FEEkert <50 sql. S50 --`25AM30'11 $15° ------ --FROZENDMIE101r S40 NAME MANGE: SI5 AMOUNT DUE = *""Pizass MIN OVIZ AND COMM=011DOISIDE OF FORP4e*".* if ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Ya mndh is now required to Led 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 AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR • CERT.OF INSURANCE ATTACK - OR „) WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED 17_ Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES___. _ NO - • MOTELS AND OTHER LODGING ESTABLISHMENTS ' TRANSIENT OCCUPANCY:For purposes aftheliHotel oteluse,T y occupan shaft belimiledm the temporary and short term occupancy,ordinarily and custmnanly associated with motel and hotel use. Transient occupants amt have and be able to demonstrate that they maintain*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 trtmsient 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 impeded Health Department prior to opening. Contact the Heath the schedule inspection t'hr ee(3)days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TFSITNG: The water Hunt be tested for total coliform and standard plate count by a State certified lab,and submitted to the Health Department three i )3 to opening,and quarterly thereafter. -POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of FOOD SERVICE SEASONAL FOOD SERVICE OPENING: MI food service esabiisbmmis must be inspected by the Health Department prior to app. Please contact die Health Department to schedule the inspection three(3)days prior to opeumg. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department , n• the -, ,• _, Temporary Food Service Application form 72 hours prior to the catered event These forms can be ,, � _, at the *, Department,or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts mint betested byaState certified lab pnortoopening and monthly tm with sample nseudssubmitted to the H ealtterms Failure to do so will result lathe sr sion or revocation of your Frozen Dessert Permit until the abovet. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,per,or display of any food product by a retail or food service establishment is posturer. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits rimannually from January i to December31.ITIS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (Le., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND API ROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY A SII DATE: ///d 7 /8 SIGNATURE: > / It�i. Air PRINT NAME&TITLE: /tet n da Y4 Q m i/71Z,r1 , C)l tun e e Rey.mains