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Home My WebLink AboutApplication and WC C-C. C�ttUo DEvv�z-oPiK�- � � TOW1Y OF YARMOUTH BOARI?OF HEALTH� , AR. Pe�S�ooi... � � � APPLICATION FOR LICENSE/PERM �'!� 2 � ' '� � `- =� '' " = , . .��,, �t�i�� ;, ' * Please complete farm and attach all necessary dt�cur�ents 'y Dec rnb�.� � FaiTure to do so will result in the return of your applicatron ac��T ESTABLISHMENT NAME: TAX ID� LOCATION ADDRE5S: TEL.#: MAILING ADARE : OV4�NER NAME: J CORPORATION NAME ( F PLICA E): MANAGEIi'S NAME: � TEL.#: - MAILING ADl?RESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desienated Paai Operatar(s} and attach a copy of the certification to this form. I. 2� Pool pperators must list a minimum of two employees cun•ently certified in basic water safaty,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this Fonn. The Health Department will not use past years' records. You must provide new copies and maintain a fiIe at yonr place of business. I. 2. 3. 4. FCIOU PROTECTION MANAGER5 - CERTIFICATIONS: All food service establishments az-e reqnired to have at least one £ull-time employee who is certified as a Food Protection tvSanagez•, as defined 'u� the State 3anitafy Code for Food Sei�ice Establislunents, 105 CMR 59Q.4QQ. Please attach copies of certification to this application. The Health Department will not use past years' records. Yau us avide ne � opies and maintain a Sle at}our estabtishment. 1 ° 2. ' ? irtr PER50N 1N CHARGE: _ £ac�food establis�ment i �ave at Teast one Yerson In Cliarge(PIC} on site during hours of aperatian: L � 2• HEIMLICH CERTIFICATIONS: All fopd service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Flease ]ist your empl�yees trained in anti-chokme pracedures below and attach copies of employee cei�ifications to this foim. The Health Deps�rtment�vili not use past years' records. You must provide netv copies and maintain a fite at�=aur place of basiness. �. �._ �' �+n��f 1�C�� z. '1�t 'Uc:�a1a� 3. �i1 Ylc'�a�� 4�--� � — RESTAUFtANT SEATING: TOTAL # ' OFFICE USE CiNLY LODGI\G: LICENSE REQUIRED FEE PERMII#� LICENSE Rk:QUIl2ED FEE PE2'vIIT* LICENSE REQUIRED FEE PERMI7# B&k3 S�5 CABIN S55 _ _„_MOI'EL S55 _„ � i111Q S�3 CA;YfP Sii ��'I1'L�3TNGFOOL S80eu. _L011GE S55 __, `TRAILERPARK SIOi �S�T�IIRLP06L S84ea. FOOD SER�'ICE: LICENSE REQUIRF.D FEE PER'�IIT*= LICEN5E REQUIRED FEE PEFL�4IT� LICENSE TtLQUIRED FEE PF.R:�II?LL -^� 0-IOOSEAI'S S85 _CpNTINI?NIAL 535 _ _�NQN-PROFIT S30 �L_;_a�J' / i„_>100SEAT5 SlbO �� CONLViUN�'IC. S60 _«'HOLESALE S80 RETAIL SERS'ICE: —RESID.k3TCHEN S84 LICENSE RL-QUIRED FEE PER�IIT� LICENSE REQUI2tED FEE PER�IIT# LICENSE REQL'IRED FEE PERVIIT� �<SOsq.B. S50 _ >25,OOOsq.ft. 5225 ��ENDING-FQOD S25 ,_ . <25,000 sq.it. S80 _.._FROZEN DESSERl' Sd0 TOBACCO S55 ti.a�cxa�cE: sts AMOUNT DIIE _ $ 30. 00 ****'PLEASE TCR�OVER A�D CO�IPLETE OTHER SIDE OF FOR33"•*"" ADIYIINISTRATION , ' 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 CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits: FLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER I.ODGING ESTABLISHMENTS 'I'RANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel 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 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 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 are NOT allowed to srt in the pool area unril 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 OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Hcaitn Department to schedule the inspect�on three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yazmouth 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.yarmouth.ma.us under Health Department,Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and montlily thereafter, with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernrit until the above terms haue been met. OUTSIDE CAFES: Outside cafes�i.e. outdoor seating with waiter/waitr�ss servica�,must haue priorap�rnva�frc�m theBear�efHealth. _ _ �- - OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. N01TCE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER I5, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISf�1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ SITE DATE: I I 1 I 1 � SIGNATURE: --�--r �' Co du�lor PRINT NAME&TITLE: io�oe�io � ' � 9 � The CommoxweaJth af Massachusetts - Department ojlndu.�tria!Accide»Ls ' N��N�dws d0U Washi+rgtoa Streey J"Floar ' Boston,Mass. 011ll Workers'Compensatios I�naranee Atfid�vH: Bqiidiag/PiombiaA/Ekctriral Cawtractors namt: . � � �`�VC.,�.+�� ,�s: � �� _—_��_v'I ___`��y_C�%{--- --r�_^� — ---- —_ --- i ra[e: &io'4/�,�:�,� vha�i N ��'��,�, "'�� , worksitelocatianlfi�,addressY � �L�� Q.-�'�_r�� YUc,_y�"'.fi �`r �.,,a:�'!'�--�r �''1( , ❑ I am a hocneawncr pezfartning all work myse[f. 3koject Type: New Co�:tion[�Remodel ❑ I am a sole proprietor and have no one working in any capec'rty. [�Building Addiiion UV I arn an employ providing workcrs'compensation or my emp! es wodc'rng oa this job. . A � l f00 C: �.�� . id � "' � .. A+ ( .�� .� � � � tM' '� � v�r � �Yt 10E CO.� � h_� � � ❑ t am a sote proprietor,geocrsi�qetrxtor,or hameowner(circle one)and Uave hired the conhactas listed below who�have the following wackers'compen,Ration policac: �mnuv rame: ddrna: �.�'_ nbaee M• inar��ee rta. dMkr M SOONdY HY1!' . �' C�': O►o�e M' i�mrte ts - . .. �_ ... pdkr 1f . .. � . +iY�eY Mirr�t iwt K�rr�w� . . . . . FaYac e�aec�uz ev�aa�e n drad�rdv SMMn 2SA K MGL 1S2 tu kW b Me L��fa��d ge�Mlka 4a ie wp b S13M.M aidt�r �Ytin'�P��wt •dH penaNb M t�atf STOI'WQICK ORDER atl�oee d`31M.N a day�alst ie. 1 e�da�/f�M tdl a �MY�f tW y 6e f b� �tirve�C�tl�a�ef tYc DIA far awe�e verNarMa / I do Rereby certlfy w( nie yWfns er:ofperJwry tha�rhe iwfonwmMn proviled abowr!s trpa m�d t " . y,/p-�-'- , � . 3ignanue . `^.yn�/rl{�S � ^•�".-^--"---��... Data �i� . � � r. :��.� - _ _ _._ - . _ . . P�� Phonc B �� oifleld ux onty Ao nw wrMe 4 INs am b 6e cerplefed Ay eNy or oBkW . . . c#y or tewo: �p . ❑BnidleK DepuOment ❑tbeet Ui�mc�tlt!re�pseee 6�psircd � Qi.tc��t HmrA Q5ekaime�'s(N9ee �es�sMtt petwaa: Pb�p. �t--e.�.�� t2+r.1 wy�mat� �^bQ .