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Home My WebLink AboutApplication and WC .. . � TOWN OF YARMOUTH BOARD OF HEALTH F� � ; � ' �� APPLICATION FOR LICENSE/PERMIT - 2{1�2 �� P �O 11 �� * Please complete form and attach a11 necessary documen� h��'6e IS T��pT. Failure to do so will result in the return of your ap�t�cation pac e ESTABLISHMENT NAME: e �O G(n r( L'vP�o �e�q • � LOCATION ADDRESS: 36'7 R • a s l�eST yA� r+o� 0,36"]3 TEL.#: SOS `1/� �SS7 y MAILING ADDRES S: f3 3 ea r I s'r. I-��/w h n i s M i� Da- 6 D I OWNER NAME: CORPORATION NAME(IF PLICABLE): MANAGER'S NAME: A-v+�i^B�J IZ�/S TEL.#: S08 `llb' SS/ `I � MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard 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 copies and maintain a f'ile 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 certi�ed 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 establishmen� �. �no�re�✓ �ys 2. _ --� , �- � ,r,,r� . ` ,, PERSON IN CHARG�: !' Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �. _ Pa� � I-� o � �, l.�to � 2. HEIMI,ICH 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 Heaith Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 4h�rG�./ �y s 2. PAv I A �IO J I� �04 3. ' 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGWG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FF,E PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 - _CAMP $55 _SWIMMINGPOOL $80ea _LODGE $55 _TR�.Fu pARK $105 _WHIRLPOOL $80ea F90S5HRYICE: • LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE �PERMIT ii �LIC,EN5B Ri:�U1REU�FEE -P�I2MIT# -_. _0-100SEAT5 $85 _CONTINENTAL $35 I NON-PROFIT $30 � '�(� _>]00SEATS $160 _COMMONVIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 3Q.OO •a•*+PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**�k� , .. 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. TFIE 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 taxes and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS A1R'D GTI'IER Y.�IDG:N�F3'FABLISIL1�fENTS 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 CMR 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 Departrnent prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PL,EASE NOTE: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, 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 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. CAT'ERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth 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 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: vu�&iC�iC CBiES�I.C.�Oil`�i�av^O�SCSiL'I'bT W`�ui k'uii.Ci��`r"11t2'ESs 5�,:✓IC��IIillSL�73VC PIIC:$�1'QSii.l�T'OTI1:hC�02SC1 Of NC21�.h. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. pi.i. RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIvIENCEMENT. RENOVATIONS MAY REQUIItE A STfE PLAN. DATE: I � SIGNATURE: PRINT NAME&TTTLE: � �t r i fii �n r �� 7�ch'' Rev. 10/25q1 . � � �� The Commonwealth of Massachusetts Deparbxertt ojlndustria/AcciJen[s N�eaNrws�tll�s 600 Woshington Street, f�F[oor Boston,M�u 011ll - . Worlcers'Compeesatios Iroannm Slftidav�:� . � . . � . . � . - . . PIeLe PRIN'f k�61� namc: C�o, (iVl i �. . . : � .. L� o. n' vi . �. ' . addte.ss__S1_.__ eAr��/ __ _ . ___ city Ny(n�1 N� S statr �-/ R zio� �c�-60� ohone# .S�B �� B .�.�� / �n s�re i«e�;��rwi aaa�r. 3 6 7 R-� a s I�Ps t�/�t rr o v� ►�I f� Oa 6 �3 ❑ I am a homeowner perfotming all waic myself. ❑ I am a sole proprietor and have eo one working in any capacity. � I am an employer providing workecs'compeosation for my employees wodcing a�ihis job. commernme: p2��p�p'� � _l./�� `��JeLB/�JMPvI-'�""�-- � -:.—... _. .. .aaro.- g 3 r�ar I s f �,.:��h� �s M /} 03601 �r: �0� yl8 SS/9 lmea�ee ca G t'�ar ff s vl 1�O�J O odkv A �.5� � / �J o�0'J� . . .. � . . ... .. . . . .. . .,. . ❑ I arn a sole proprietor,ge�erai eo�frxtor,or Yomeewner(cnclt owt)aed have hirod the contractas listed below who have � t!�following workers'compen4ation polices: . � moour s�e• . . �� - ad�na• db' oYose R' iovaKe ee. oallev M c000uv nme• ad�• et�• oYo�e M- Irqasce eu oaliev# AI�l.+rrrr:rner...r.T � . �. . . . . .. . .. 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