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Home My WebLink AboutApplication and WC , c+� AurN�7unc THq�Cv�siNE a TOWN OF YARMOUTH BOARD OF HFA� � , ,, �� APPLICATION FOIt LICENSE/PE1iNIIT':2OQ�9 ��,�"� ' ` ' ' � ' " � �� * Please complete form and attach all necessary documents b ecemb l��l'�O�t.� Z008 Failure to do so will result in the retum of your application pac •h`�L�-� v�PT. NAME OF ESTABLISHMENT: `� C��d- �3 Gt S AU hP,�n.�1�C '�'tG", EL. # g �� g9 LOCATIONADDRESS:_ Sq �F MGi� t�- w yaYMOtI � a- 7 MAILING ADDRESS: SAM-e- OWNER NAME: �AV M\''v�r�n � �� ^^ TAX ID (FEIN or SSNI: CORFORATION NAME (IF PP ICABLE): MANAGER'S NAME: (`�I L'�Q-� N 1�e c1�"� S i� TEL. # 5� �� MAILING ADDRESS:_$g �l �`�tG�ik � W 7C�Y�Gv� -� cy�-C�`7 3 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. 1. 2. Pool operators must list a minunum of two employees cun•ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at Yeast one fixll-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. �. l��ts fi� P,� M��o 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site dIu� ring hours of operation. 1. �LC1cl N4o c�r+� S-, '�"'� �'� I v�^-� 2 �"2�n T �1��/G✓� S P�. 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 Health Department will not use past years' records. You must provide new copies and maintain a Gle at your place of business. 1. i' ��l��k �r;yo r,,S,•�. 2. 3. 4. RESTAURANT SEATING: TOTAL # � � OFFICE USE ONLY LODGItiG: LICENSE REQUIRED FEE PERMIT t? LICENSE REQi11RED FEE PERMIT k LICENSE REQUIltED FEE PERMIT# _B&B S55 _CABIN 555 MOTEL S55 _r`+� �» _CAMF S55 _SR-'i1�IIvIINGPGOi SSOea. _LODGE S55 _TRAILERPARK �105 WHII2LPOOL SSOea. FOOD SERVICE: LICENSE REQLJIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# �0-100 SEATS S85 ��l� _CONTINENI"AL S35 NON-PROF[T $30 _>100 SEATS 5160 �COMMON VIC. 560 ��b _WHOLESALE 580 RE'IAII.SERVICE: —RESID.KI'ICHEN �80 LICENSE REQU[RED FEE PERMIT# LICENSE REQUIItED FEE PERNIIT# LICENSE REQiJIRED FEE PERMIT# _<SOsq.B. S50 _>25,OOOsq.B. 822� VENDING-FOOD S25 _<25,OOOsq.ft. 580 _FROZENDESSERT S40 'IOBACCO S55 �.a�iEcxa�cE: sio AMOUNTDUE _ $ 1'�S. 00 *"*"*PLEASE TUR\OVER A�VD CO.'VIPLETE OTHER SIDE OF FORNI**••* ADMINIS'I'RATION Under Chapter 152, 5ection 25C, Subsection 6,the Town of Yazmouth is now required to hoid issuance or renewal of any license or pernut to operate a business if a person or company does not haue 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 Yazmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CFIECK APPROPRIATELY IF PAID: �/ YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shallbe limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be abte to demonstrate that they maintain a principal place ofresidence 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 s'vf(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 swimrrring,wading and whirlpools which have been closed for the season must be ins ected by the Health Department prior to opemng. Contact the Heahh Department to schedule the inspection five(S�days pnor to opening. PLEASE NOT'E:People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WA1'ER TEST'ING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, 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 CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yarmouth Heakh 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemut 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 ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIIdTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2008. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAIN'TING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. S�' ' � -f' i` � DATE: r� /� �4� SIGNATLJRE: "�""�Y�^ � r � � � PRINT NAME&TITLE: 10Y21108