HomeMy WebLinkAboutApplication and WC /.4;;"---ik'•-• ,...... \ TOWN OF YARMOUTH BOARD OF'i...,iALTH
lti_ITV\ APPLICATION FOR LICENSETERM-'.'="-2020
*Please complete form and attach all necessary thwFrnents by December 13.2019.
Failure to do so will result in the return of vi:.:. application packet.
NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST Ri`T:,..-!.!`,N?FORMS BY NOVEMBER I5".
ESTABLISHMENT NAME: q.)1750-irifi MA-OS TAX ID:
LOCATION ADDRESSa'2 c. - 0 4 Oa/iii.0 ore ifeij,,,f-,YkoitEL.#: 06ci-
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MAILING ADDRESS: 2 "P -old ac04;c Rof iSotok jeiren -i/r)4 -a
E-MAIL ADDRESS: 4 s i t! A al 1.
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OWNER NAME: Bta. .rail, ,' -
CORPORATION NAME(IF APPLICABLE,: g,. A,,T CO7,
MANAGER'S NAME: cefell kola , TEL.4: ?CS-9/0.3
MAILING ADRSS: tan&frg Arew
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POOL CERTIFICATIONS:
The pool supervisor must be certified as a Panl t%ieratcr,as require",' : State law. Please list the designated
Pool Operator(s)and attach a copy of the certifization to this form.
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Pool operators operators must list a minimum of two elnplo:,ees currently certif ' ,-: standard First Aid and Community --I c) 6,.0
Cardiopulmonary Resuscitation(CPR),havhia :ir,„:.certified em.,ploye,.. . ;yr,::thises la all times. Please list the I co [gil
employees below and attach copies of their certiiiimtions te this term.Ti.., ,--!litaith Department will not use past
years'records. You must provide net' copla.:i.r-1:1 itta;..t.tt-eit t,file i ' 'le place of business.
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FOOD PROTECTION MANAGERS-CERT C-AI-IONS:
All food service establishments are required:o have at leas; one full-'. . . eapioyee who is certified as a Food
Protection Manager,as defined in the State Sanitary Code for Food Sa, '.,i,-Establishments, 105 CMR 590.000.
Please artaeh copies of certification to this appliaatioa. The Health Dep a.-,:rent will not use past years'records. .. ,
You must provide new copies and maintain 2 file at your establisat. -.. .
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PERSON IN CHARGE:
Fath food establishment must have at least one'!k-..-•-son to Charge(,P1C' .: ,l'e curing hours of operation.
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ALLERGEN CERTIFICATIONS:
Ali food service establishments are required to have at least one full-tirni. .,i);oyee who has Allergen certification.
as defined in the State Sanitary Code for Food:San ice Establishments. '.`','MR 590.009(0)(3)(a). Please attach
copies of certification to this applicaticn. Th?Pealth Department w:: -' rise post years'records. You must
provide new copies and maintain a file at yr•-,,,,r.astablishrnent.
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HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats::.,-1-It-ire mils:,have at la'a . ne employee trained in the Heimlich
Maneuver on the premises at all times. Please list you:employees tram l.1 anti-chokine procedures below and
attach copies of employee certifications to thit:::'aea-i. I he iieliKt Depar.:,.:cnt will not use past years'records.
You must provide new copies and maintain a fie at)ciau place of h:::,..,ess.
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RESTAURANT SEATING: TOTAL# 66 pcf—I S---151 3-05
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OFF:"CE USE ONLY
LODGING:
LICENSE REQUIRED FEE Pt Rmn-4 Licy,Ns REcItiR'=.0 F'- ?E.RMI: - LICENSE REQI.111E1) FEE PERMIT 4
MB $55 cAilii.., 555 MOTEL $110
--INN $55 CAI,T 555 —SWIMMING AXIL$110ea.
7-LODGE $55 _._ :TRAii.,.:k?ARK 511)5 WHIRLPOOL SllOca.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT 4 LICENSE:n.QUIRED I-El. FERMI-. LICENSE REQUIRED FEE PERMIT II
0-100 SEATS $125 CON-,INZN I AL 'i35 N;UN-PROFIt $30
>100 SEATS $200 .`..j.".”,f,,:u:\VT.(' :-.,.z,- ,,,:i,')LESA LE $10
__:-.- -.4'.ES1D KITCHEN $80 ---
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT; LICENS;-.1-1i.'OCIM;.D ;',.:1.., 'E?\41 1,.C:.NSE REQL:IRED FEE PERMIT 4
<50 Nit. $50 --,25-p.10 sc-' 5L5 VENDENG-FOOD $25
4-'25-000 49.fl• $150 IsLtil --FRGzHN bEssER r .:34i- __ ' '.)EV2C0 £110 -4---ZIO
NAME CHANGE: $15 p - ..11374iT DUE = S --,4Cct.T.i'.CC
'****PLEASE TURN OIL F.:.7 .)COMPLETE OTHER I: ._7 OF FORM"-
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ADMINISTRATION
Under Chapter 152,Section 25C.Subsection 6.the Town of Yarr.nouth required to hold issuance or renewal
of any license or permit to operate a business a ',pers.on or company not have a Certificate of Worker's
Compensation Insurance, THE ATTACHED STATE WORKER ..7:01VIPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OFl!'..S...,...;RANCL A'r 1ACI1ED
OR
WORKER'S COMP.AFF DAVIT SIGNED AND.4:7'. AC.
Town of Yarmouth taxes and liens must be paid':prii tr to renewal or issueein of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES V
NO
MOTELS AND OTI1ER L01)-(7NG ! ST .,1.17i4IMEN TS
TRANSIENT OCCUPANCY: For purposes of the iirrzilations of Motci or Henn tee Transient occupancy shall be limited to
the temporary and short term occupancy.ordinarily:tel customize-4 assoinated )n: octet and hotel use. Transient occupants
Must have and be able to demonstrate that they maintain a principal):place of re.i Teen elsewhere.Transient occupancy shall
generally refer to continuous occupancy of not more than thirty(30)days,and ;ggregate of not more than ninety(90)days
within any six(6)month period. Use of a guest unit as a residence or detcnene unit shall not be considered transient.
Occupancy that is subject to the collection of Rome Oncupancy Excise.as de M.O.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 nnee ror the season must be inspected by the
Health Department prior to opening. Contact the Hazen Department to schka ,.7::the inspection three(3)days prior to
opening.PLEASE NOTE:People are NOT 0110Wej to sit in the pool area mni'. pool has been inspected and opened.
POOL WATER TESTING: The water must be teate.J.for oseudamonas, ::;J:.fforrn and standard plate count by a State
certified lab,and submitted to the Health Department three(3)days prior to on e,and quarterly thereafter.
POOL CLOSING:Every outdoor in ground s' iL poo in .t be drainer. ,u‘,,,ered within seven(7)days of closing.
ram)SER7VICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspectec lieHealth Depart-men': to opening_ Please contact the Health
Department to schedule the inspection three(3)daya Fkpr c ups
CATERING POLICY:
Anyone who caters within the Town of Yannoath Depanmerit by filing the required
Temporary Food Service Application form 72 hours prior to the cater:d eyed. .Hhose forms can be obtained at the Health
Department or from the Town's website at www..varrryyatt_nta.as LiadtT Heats Downioadahte Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified 7.ab prior to opening and mc 'fr.' etereaftenenith sample results submitted to
the Health Department. Failure to de so will res"in the inspension of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiterAvaiirasa s;.,--rvt.:f.,must!uve p... 7,1.)rova)from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any fore c.,,roduot bye etail or icoO :,,.f.rvice establishment is prohibited.
TOBACCO PRODUCT PERMIT sP
A tobacco permit holder who has failed to renew his or her permit V/Ah , 'Lhirty(3 )days of the previous year's
permit expiration date is considered an expired license.and the lohaen).). cap is reduced.
NOTICE:Permits rim annually from .-1-]..eceni,er 37. IT IS, RESPONSIBILITY TO RETURN
THE COMPLETE!)RENEWAL APPIA('ATICY4S)AND REQUIR T`';EE(S)BY DECEMBER 13.2019.
ALL RENOVATIONS TO ANY FOOD OR POOL (i.e., PAINTING, NEW
EQUIPMENT.ETC.).MUST BE R.E.PORTED TO AND i'IPPROVED THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A.)SITII
DATE: 9 SIGNATURE: x,e,„zzi
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