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Home My WebLink AboutApplication and WC . ., . O-----... (17 ' TOWN OF YARMOUTH BOARD OF HEALTH ki-;":;) APPLICATION FOR LICENSE/PERMIT-2020 \-,...-,,,, *Please complete form and attach all necessary documents by December 13,2019. Failure to do so will result in the return of your application packet. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15m. ESTABLISHMENT NAME: 0011014-Arilikirpilefirig LOCATION ADDRESS: 2. 6 nida.A.MIFT7 zelere 2. g TEL.#: 50, us-26,2_, MAILING ADDRESS: (6 WI• #01- k 0.2.6* q5 E-MAIL ADDRESS: 0-Lt...0.et kl VT ry-taL444. i 10_3 nn ei.Lt OWNER NAME: _ ,)' O-7l co---t- t---- 1 CORPORATION NAME(IF APPLICIALWc,JOL.-)1 f_Sri(e< LL-em p MANAGER'S NAME: - --0(-Ci TEL.#: 507C975- 7 -- ni CD [1111 > " MAILING ADDRESS- r (,,) _A __..% u ill co L POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated 01 CD Pool Operator(s)aid attach a copy of the certifica* n to this form. 13 -..... L.) --I CO I. C6,-ttl K1 Po 2. Pool operators must list a minimum 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 this form.The Health Department will not use past years'records. You must provide new copies aid maintain a tile at your place of business. :,..71:461\ I. PoL2. .. , 3. 4. .,c. 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, 105 CMR 590.000. 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. -,1-e3- ) '''q PERSON IN CHARGE: Each food establishment must have at least o c Person In Charge(PIC)on site during hours of operation. • t I. .-..i ill;_.-__-•. b.1,4,„„li i _.v.-...;.-.. 2. k'i'a-Ceiv-i OA-A/ ALLERGEN CERTIFICATIONS: 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(G)(3)(a). 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 y' r establishment. -1--.. f,,f .0001,-_,- .--1170. /-?-e,,, ,e9 / 1. „,,,,„,, 2 HEIMLICl I 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 al:times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'records. You must provide nev,'copies and maintain a tile at your place of business. .... 1. iit. .Tiiiii,. _ ,..---......--...10•00 2. 3. 4. RESTAURANT SEATING: TOTAL# 045e.--(5--l 777--(NS' OFFICE USE ONLY LAMING: LICENSE REQUIRED ,EE PERMIT 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE 138413 355 CABIN $55 ..1_MOTEL $110 —INN 355 -- CAMP $55 j_SWIMMING POOL$110eit. —LODGE $55 _ - --'MAILER PARK $105 ._WHIRLPOOL $110ea. _ FOOD SERVICE: LICENSE REQUIRED .,FE FERMI f i LICENSE REQUIRED FEE pF.ANtrr 4 LICENSE REQUIRED FEE PERMIL# 0-100 SEATS $125 _L CONTINENTAL $35 NON-PROFIT NON-PROFIT $30 >I uo sEATs 323() _ COMMON VIC. $60 _ _ WHOLESALE $80 RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED '1E, PE,UvIIFI LICENSE REQI IRE') FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. 350 >25,300 sq.ft. $285 VENDING-FOOD $25 —<25,000 sq.fi. $150 —FROZEN DESSERF$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ d55.00 ,,,,-'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 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 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 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 unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise,as defined in M.G.I,.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 inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening.PLEASI.NO 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 count by a State certified lab,ad 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(7)days of closing 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 obtained at the Health Department,or from the Town's websitc at www.yarmouth.ma.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 Deoartment 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 COO KING: Outdoor cooking,pieparation,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 da-„c is considered an expired license,and the tobacco license cap is reduced. NOTICE:Permits nin annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13,2019. ALL RENO VA 1 IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TILE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: (ft J' SIGNATURE: PRINT NAME&TITLE: , Rev.10/15/19