HomeMy WebLinkAboutApplication and WC . . �. �
�� TOWN OF YARMOUTH BOARD � H " "� � —-
• ���� APPLICATION FOR LICENSE/PE ;�'"
I¢OV' C'T, 2:�i11i1
* Please complete form and attach all necessary cuments by ecem r l l.
Failure to do so will result in the retum of your application pac �[.
ESTABLISHMENT NAME: d�1 TAX " � �
LOCATION ADDRESS: � S• !'� TEL.#: � ' 'IGO U�U
MAILING ADDRESS: c7
OWNER NAME: �
CORPORATION NA IF APPLICAB ): Z v M �✓IC�
MANAGER'S NAME: -u�t�U LA- TEL.#: ' - /D _3(0
MAII.ING ADDRESS: Q �c� L
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.
L 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid
and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of
employee certifications to this form. The Health Department will not use past years' records. You must
provide new copies and maintain a�le at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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�le at your establishment.
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PERSON IN CHA�iGE: _ _
Each food establishment must have at least one Person In Charge(PIC) on site duruig hours of operation.
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HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heixnlich
Maneuver on the premises at all 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 new copies and maintain a file at your place of business.
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RESTAURANT SEATING: TOTAL# ��'G�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT#
_B&B $55 _CABIN $55 MOTEL $55
_INN $55 _CA2vIP $55 _SWIMMWGPOOL $SOea.
_LODGE $55 _7'RAIL,ER PARK $105 _WHIRLPOOL $SOea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LiCENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0.100 SEATS $85 _CONTINENTAL $35 _NON-PROFTT $30
L>]00 SEATS $160 Ia'��" �COMMON VIC. $60 I�'O�'j _WHOLESALE $80
RETAILSERVICE: —RESID.KI7'CHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICE[VSE REQUIRED FEE PERMIT#
_<50 sqSt. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25
_Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $IS AMOUNT DUE _ $ 2 Za. 00
•***3PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*k#+•
M •
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 ��,r;�S\�
�!Y/
CERT. OF INSURAlVCE ATTACHED CT''�c,�'
OR � ,�
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID: � NO
YES
MOTELS A_hiI! OTFIER Lt;DGi�� �:STr�LISI�I�IEEIVTS
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 demonsuate 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.L. c. 64G or 830 CNIl2 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPEIVING: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
pnor to opening.PI.EASE NOTE: People are NOT allowed to sit m the pool azea until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliforni and standazd plate count
by a State certified tab, and 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 OPEIVING:
All food service es[ablishments 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.
CATF.RING 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 website at www.varmouth.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 DeparUnent. 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:
f3utside ca:es(iz.,�atdac.seating with�siterlwa:tress�er�:..e),r_�st::.:v:,prie:agprova�€wm th:Board af Hez1Lh.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
TFiE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2011.
AI.L RENOVATIONS TO ANY FOOD ESTABLISI�MENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, F,TC.),MUST BE REPORTED TO AND APPROVED BY THE BO -f3F HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL�
DATE: I_ fT�ll SIGNATURE:,/,-(,� M �
PRINTNAME&TITLE: �Jen SV2P�ENAch1T
Rev.10/25/i]
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Departixeat of Industria!AcciJents �' �GJ�/� _� n�
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❑ I am a homeowner perfoiming all wodc myself.
❑ I am a sole proprietor and have no a�e wocicing in�y capaciry. �
�Q I am an anployer providing workers compensation for my employees wodcing on ihis job.
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CERT�ICATE H�QER CANCEt.I.AY10M
Town of Yarmouth Liaense Dept. �'-o�r�r�aewe c�scweEo ro�u�Es ee cr�wce��o e�ottE
THE E%PIRATIDN OA7E THBREOP, NOTCE VYILL BE DELNERED IN
1746 Route 28 acccRaaNce wmi n�� aoucr �ows�cNs.
Sou[h Yarmouth, MA 02864
AUTNOR2EOftEPRESENTATHE.
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�9198&2010 ACORD CORPORATION.All rigAts raserved.
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