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Home My WebLink AboutApplication � TOVYN OF YA2tMOUTH BOA.RD OF,�IEAL,T„H . �` `� ' �` � � � APPLICATION FIJR LICENS��%1�RM,I�.�20 � ho�� n� � �� . �� Z�� * Please complete form and attach all aecess&ry ertts Dec b P�. Failure to do so will result in the retvrn of your applicatian ESTABLISHMENT NAME: � /P� � i� ✓TjA(/R�,+ • LOCATION ADDRESS: c��o�, /'�� N -jT T. +.� TEL.#: S�d � `J.� �'s�`5 MAII.ING ADT3RESS:_ Siv�+r P 4WNER NAM�: �Y CORPORATION NAME(IF'APPLICABLE): Cr� 4 � � A,( -��'- D �'+/L- /L- -, MANAGEIZ'S NAME: J�I3i.ld: /L r TEL.#:, Zv1AII.ING ADDRESS: �? � POOL CERTIFICAfiIONS: The pool sapervisor must be certified as a Pool l7perator,as required by State law. Please list the designated Popl Operator(s) and attach a copy of the certitication to this form. 1. 2. Pool operators must list e minimum af two employees currently certified in basic water safety, standard First Aid and Community Cardiopuimonary Resuscitation (CPR}. Piease list these emgloyees belaw and aktach copies af employee certifications to this form. The Health Department will not use past years' records. Yoa must provide new copies and maintaiu a fite at your place af busiuess. i. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All foad service establishments ;tre required to have at least ane fuli-time employee who is certified as a Food Protectian Manager, as defined in the State Sanitary Code far Pood Service Estabiishments, 1Q5 CMR 59Q.Q00. Please attach copies of certificatian to this application. The Health Tlepartment will not use past years'records. Yau must provide new copies and maintain a f'ile at your establishment. 1. G-' C� V-i A�i2#�R/rv c:7 2. �� C.!//Yr�t/f�Lc: P�(2SONRaIC�3ARGE: _ . _ _ _ _ ____ __ _ ____._ _ . _ _ ___ --, Eaeh food establishment must have at ieast one Person In Charge (PIC) on site during hours of operation. 1. r'�_,�,-,%�/Ld�,� 2. „�v� V'i�.�2r�i'�t�+ HGIMLICH CERTIFICATIQNS: All foad service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at aii Cimes. Please list your employees traisied in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will pot ase past years'records. You must pravide new copies and maintain a�le at your place af business. , l. �� r/�:Lf�/N� 2. �'� �'/i��i//L� 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQllIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUll2ED FEE PHRMiT# �„B&B $55 _„_CABIN $55 _Ml1TEL $55 -= ="---..s� --�- _.__.___{Nt�T------$�5--�-- - -----=Clv'v:� .. _. . .$59 � _SW4'vLLiiNGb'("JOL $80ea. _LOLIGE $55 �TRAtLERPARK $165 „_WH3RLFOQL $80ea � FC70D SERVtCE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 �NQN-PROFI'f $30 1,>100 SEATS $160 A4(� �COMMON VIC. $60 �(a -D 3I �WHOLESALE $80 RETAII.SERVICE: —RESID.KI1'CHEN S8Q LICENSB REQUll2ED FEE PERMiT# LICENSE REQUtRED FEE PERMIT# LICEI3SE RE¢U![2ED FEE PERMIT# _,,<56 sq.fr. $54 _,>25>00(a sc7.ft. $225 �VENDING-POOD $25 �GtS,t�sy.ft. $80 �FROZEN DESSERT $40 `TOBACCO $95 NAME CHANGEs $15 AMO[JN'T DT.7E _ $ 2-2-O.txj *3***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*�'** ADMINISTRA,TION � Under Chapter 152,Section 25G Subsection 6,the Town of Yannouth is now required ta hald issnance or renewal of any license or permit ta operate a business if a person or company daes not have a Certificate of Worker's Compensation Insurance. THE ATTACI�ED STATE WORKER'S COMPENSATION INSURA.NCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OA CEtZT. QF INSURANCE ATTACHED � QR WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED Town of Yumoath ta,ees and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO -----____ ___ ___.____.�S9T'EI;'�s A1Vll E?Y'Pff?��:6�3+�i:��S`P:�LI�I�'v1EiV"i'� -- TRANSIENT C1CC[Jl'ANCY: For purposes of the limitatians of Motel or Hatel use,T'ransient occupancy shali be limited to the temporary and short term occupancy,ordinazily 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 eisewhere.Transient accupancy shali generaliy refer to continuons ocenpancy of nat more than thirty(34}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 Rootn Occupancy Excise,as defined in M.G.L. c. b4G or 830 CMR 64G, as amended, shall generally be cansidered Transient, POOLS POOL QPENING:All swimming,wading and whirlpoots which have been closed for the season must be inspected by the Health Department prior to opening. Cantact the Health De�artment to schedule the inspection tlu�ee(3)days pnor to opening.PI.EASE NOTE: People are NOT allowed ta sit xn the pool area until the pnol has been inspected and opened. POOL W ATER TESTING: Tha water must be tested for pseudompnas,total coiiform and standard plate count by a State certified lab, and submitted to the Health Departrnent three (3) days prior to apening, and quarterly ihereafter. PO4L CLOSING:Bvery outdoor 9n ground swimming pool must be drained or covered within seven(7)days of closing. FQdD SERYICE SEASQNAL FOOD SERVICE C?PENING: All food service establishments must be inspected by the Health Department prior to opening. Flease contact the Health Departrnent to schedula the inspection three(3}days prior to opening. � CATERING POLICY: Anyane who caters within the Town of Yannouth must notify the Yazmouth Health I?epartment by filing the required fiemporary Food Service AppIication form 72 hours prior to the catered event. These forrns can be abtained at the Health Department,or from the Town's website at www;x,armouth.ma.us under Health Department, Downloadable Farms. FROZEN DESSERTS: Frazen desserts must be tested by a State certified lab griar to opening and monthly thereafter,with sample results snbmitted to the I-lealth Depattment. Failure ro do so will result in the suspension or revocation of your Frazen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: t7u;s:d�c:z�eJ(i.;:.>out�cag s�t:ag w�zh wa::erttvaia•ess sera�c�),m�:st ha�re prior ap�ra�al from tl:c��ar�of T.-Iea�L'�. OUTDO{}R C04KING: Outdoor cooking,prepazatian,or display of any food product by a retail or food service establishment is grohibited. NOTICF.:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSI$ILITY TQ RETLIRN THE COMPLETED RENEWAL APPLICATION(S)AND REQLTIRED FEE(S)BX DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOdD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'I'IlVG, NEW EQUIPMBNfi,ETC.), MUST BE REP4RTED TO AN17 APPROVELI BY THE BQARD OF HEAI,TI-I PRIOR TO COMMENCEMENT. REN4VATIONS R�IAAY UIl2E A SITE L N. DATE:,�— /—' J� SIGNATITRE: � . p'.�r'.�'�G�'�i?.� PRINT NAME&TI1'T.E: .��iU�i�» �3 �. G'�t.+�2 0/�� 4,/07 Rev.I N251i I �