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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH y -� APPLICATION FOR LICENSE/PERMIT-2019 • � *Please complete form and attach all pp pp documents LICENSZY ST Rb�y i :�.may._ I / NOM Failure to do so will resin the return ofyour application packet '' :' BER 1S°'. ESTABLISHMENT NAME: - ‘1.•on.. `k•-\,4,..w... ., 'Q4 TAXID- 6LOCATION ADDRESS: \e1� ‘YNu:1NA , TEle.#: MAILING ADDRESS: 3v E-MAIL ADDRESS: -c SA vi 0.. kINS r,•(k_ Or\ OWNER NAME: CORPORATION NAPP CAB ) a ' r ME, MANAGER'S NAME: % �\� TEL#: ' c 4Th MAILING ADDRESS: 7.40,��...11. POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. Fi 1. 2. = Q ��7rl1 3 Pool operators must list a minimum of two employees currently certified in standard First Aid and Community tom" SCS? Cardiopulmonary Resuscitation(CPR),having one certified loyee on pps��ii at all times. Please list the _.. employees below and attach copies of their certifications to this fmm.The H Deportment will not use past 0 years'records. You must provide new copies and maintain a file at your place of business. m c 1. 2 :.1 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: 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,I05 CMR 590.000. i Please attach copies of certification to this application.The Health Department will not use past years'records. �l� You must provide new copies and maintain a file at your establishment. 1. 2 cS PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. eA I. 2. q„ '> ALLERGEN CERTIFICATIONS: • 4V 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 590.009(GX3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: 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 listyour employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The HealthDepartment will not use past years'records. You must provide new copies and maintain a file at your place o P business. 1. 2. 3. 4 • RESTAURANT SEATING: TOTAL# ii3.8 kA-e,-t. -{35t.- -( _1t LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT 8 LICENSE REQUIRED FEE PERMIT* LICENSE REQUIRED FEE PERMIT S —INNB&B $55 CABIN $55 `MOTEL 5110 —LODGE 855 —TRAILER PARK $105 CAMP $5 -SWIMMING POOL$1l0ea. WHIRLPOOL Sibs. FOOD SERVICE: LICENSE REQUIRED FEE F T y�{� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# (Id ,.0-100 SEATS $125$1 �'I" _,_CONTINENTAL $35 NON-PRO $30 >100 SEATS _COMMON VIC. $60 —WHOLESALE At E $80 RETAIL SERVICE —RFSID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT S sq{ $50 >25.000 sail $285 VENDING FOOD$25 -<25,000 sq.It. $150 FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ f2,6-400 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S CO ENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED . Town of Yarmouth taxes and liens must be paid ' to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or 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 wilt shall not be considered transient Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c.640 or 830 CMR 640,as amended,shall generally be considered Transient POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PLEASE Nall: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 pseurdomonas,total coliform and standard plate count 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 pawl must be drained or covered within seven(7)days of closing. i FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be at the Health Department,or from the Town's website at www.yarmoutham►.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 CAFES: Outside cafes(i.e.,outdoor Seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. • 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 run annually from January 1 to December31.IT LS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD EST• = ISHMENT, a TEL OR P lea L (i.e., 'AINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TOT P' s VED BY THE : 4 ARD 0 t'ALTH PRIOR TO COMMEN . RENOVATIONS MAY REQ 1'r- illP •,• .4 /IENT DATE: 11111 SIGNATURE: . . i PRINT NAME&TTTLE: l i�akk11�� '�\-'n=•. — • 9-SN 1ti/ Rev,10123111 The Commonwealth ofMassacbusetts r• .... - , Department ofIn�ialAcc nts Office of Investigations,.. =...-:Art__,..=-- t\ _� 1 Congress Streets Suite 100 •=1:" Boston,MA 02114-2017. .-,1: