HomeMy WebLinkAboutApplication and WC -
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a TOWN OF YARMOUTH BOARD OF HEALTH �RDEO CsR.FC[-E
' k��� APPLICATION FOR LICENSE/PERNIIT - 2012 C�v O F �d�1
* Please complete form and attach all necessary documents by December IS �A�,TH DEPT.
Failure to do so will result in the return of your application pac et."
�
ESTABLISHMENT NAME: � � `n �
LOCATIONADDRESS: / / f �97 d Oa'! TEL.#: �-.,9foo1-'J''ys'D
MAII.ING ADDRESS: W �
OWNER NAME: �
CORPORATION NAME(IF APP ICAB E):
MANAGER'S NAME: � I TEL.#: g'a?SD " ��
MAII.INGADDRESS: \/ W ` � �6
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 mnumum of two employees currently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary 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 eopies and m�intain a�le at yaue pflace af 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 copi and maintain a file at your establishment.
1. �QS�� �� n� 2.� ��N1C� � �
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(P ) srte dur' g hours of operation.
1� V \ �/U I � i(� 2. "l\�-�CJ �� ��
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 list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Iiealth Department will not use past years'records.
You must provide new copies and maintain a file at your place of�iness.
1.��5'��C l� 2. t ��YV�
3. C. 1�iD 77( 4. ( Q
P.ESTALTRr��:T SE�,TIAIG: TQiAL#�� , __ ---
Loncuvc: OFFICE USE ONLY
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT#
_B&B $55 _CABW $55
_MOTEL $55
. —�N $55 —C`�P $55 _SWIINMINGPOOL $80ea
_LODGE $55 _TRAII,ERPARK $105 _WHIRLpOOL $80ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE pF,RMIT#
_0-100 SEATS $85 _CON7'INENTA[, $35 _NON-PROFTT $30
�>I00 SEATS $160 ��o I COMMON VIC. $60 �-0�' _WIiOLESALE $80
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 s .ft. $225
9 _VENDING-FOOD $25
_<25,000 sq.fr. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 220,00
•***'�PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM»rxa+
_ � `
ADMIIVISTRATION �
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 dces not have a CertiFcate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIUNED, OR
CERT. OF INSLTRANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED
Town of Yazmouth taqes and liens must be paid prior to renewal or issuance of your permits. PL.EASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHNIENTS
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 demonstra[e that they maintain a principal place of residence
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty�30)�ys,and
an aggegate 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 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
pnor to opening.PLEASE NOTE: People aze NOT allowed to sit in the pool azea until the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
?'OOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of
cl�sing.
FOOD SERVICE
S�ASONAL 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 Yannouth 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 tke 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 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 Boazd of Health.
OUTDOOR COOKING:
Outdoor cooking,prepazation,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 RESPONSIBILITI'TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2011.
AT I. RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR OL i .fPfi�ITING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APP RD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS S •
DATE: I Z'�2 `� � SIGNATU .
PRINT NAME &TTfLE: ds� �
Rev.10/25/i l
• � The Commonwealth afMassachusetts
Departmettt of Industria!Accidenu
�N�
d00 Washington Street, �"FXoor
Boston,Mass, 011ll
Workers'Compeaeatios/osnrssce Alfldarih� . .
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�an�npbyer w�kees'compensaticxi Por my asep2oyees wodcing�ihis job.
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SCHEDULE OF OPERATZONB FOR: PAGE: 1 .
Ardeo Certif,ic te #: O1k005030285L11 . .
SOuth Side Td rri, LLC '�eiri: .
23V Whitee Pat ,
South Yarmout , MA 02664 .
OTHER WORKPLA 5: .
Ardeo .
South Side Ta rn, LLC . .
xings Wsy .
81 Kings Circ it •
Yarmouchport, 026�5 � . •
WC 00 00 O1 A .
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�z°��YA"�c TC?V�►IN OF YA�(JLTTH
0
o �N lUTT R
�3"--n°'�E'� 1 i46 Route 28 South Yannouth MASSACHUSET"I'S 02664-4492
Teiephone {50$} 398-223 2, Exi. 26$ - Faac (508) 348-083b
New Annual All Alcohol and Weekdav
& Sundav Entertainment Licensea
�aa�y x�.zolz
�PL�Ca`r�otJ FOR: J�miel Hospitaiity Company LLC
DBA:Ardea at Kiug's Way
nt�r��ss: 8I Kin�'s Circuit, Yarmouth Port
NAME OF APPLtCANT: aoseph.larniel, manager 508-362-7730
Contact person: same
Applicatian is for an ail alcoholic license for Ardea at King's Way to include alcahot service on
the outdoor deck with seating for 48. Total indoor& outdaar seating is 172 per submitted
seating pIan. Entertai.nment ta include live (up to 5 piece band) and recorded music,
amplification, dancing by patrans and TVs.
NAME OF PROPERTY OWNER: Kirig's Way Trust, 62 King's Circuit 508-362-3535
Date of Selectmen Hearing: Tuesday,January 31,2012. .
*" Please provide the board of selectmen with the new occupancy based an the Proposed Expansion/Addition of
the premises ic�luding deck ar terrace. ss
Hea#th Dept. Ccsmments: ;
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Signature: Date: C �
NEED COMPLETED FORM BY TUESDAY, JAIVUARY 24, 2Q12.
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