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Home My WebLink AboutApplication and WC � CLCD— W•`6Af.MoJTbt TOWN OF YARMOUTH BOARD OF HEALTH � , ' r��j P�� APPLICATION FOR LICENSE/PERMT� 28�0 �a6��"• -- � � ' � a *Piease complete form and attach all necessary doaau►e9f'ts`6y weir�eb IS �28b9. �'- ' � Failure to do so will result in the retum of yopr,appk��taon pac � � .. - :;-. ; � NAME OF ESTABLISHMENT: e � TEL. #f��t� �i�/�- LOCATION ADDRESS: MAILING ADDRESS: OWNER NAME: D FE or S N � CORPORATION NAME I PLIC LE): MANAGER'S NAME:. TEL. # - - � �� MAILING ADDRESS: POOL CERTIFICATIONS: T6e 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 certificarion to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard Fust Aid and Community Cardiopulmonary 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 file at your place of basiness. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIPICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as deSned 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 mnst provide new copies and maintain a file at your establishment. 1. 2. PERSON CHARGE: Each food establishment must have at least one Person In Charge(PIC) on sife during hours of operation. i. 1�1 )�'1 ��/�ll� 2. 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 mained in anti-chokuig procedures below and attach copies of employee certificarions to tlris form. The Health Department will not use past years' records. You must provide new copies and maintain a file $t your place of business. 1. �Y►� Wa�l'�✓ 2. ��,�. \n .I�,�— 3. . �L'�2►C�� 1' r� CzV�-� a. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 �12`'N . $55 _CAbLp QS' �SWIIvI�IINGPOOL �80ea_ _LODOE $55 _TRAILERPARK 5105 WI•IIRLPOOL 380ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIIt£D FEE PERMIT# LICENSE REQUIRED FEE PERMIT'# _0.100SEATS $85 _CONTINENTAL S35 �NON-PROFIT $30 0'D�oy >I00 SEATS $160 _COMMON VIC. S60 WHOLESAL£ $80 RETAII,SERVICE: —RESID.KITCHEN 580 LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE P£RM('i'# LiCENSE REQUIRED FEE PERMIT ti _<SOsq.2L $50 >25,OOOsq.R. $225 _VENDING-FOOD $25 _Q5,000 sq.R � S80 _FROZEN DESSERT $40 70BACC0 $55 x.�tE canxcE: sis AMOUNT DUE _ $ 30 ,00 *•""«PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM«"•^• i " 1 ADNII�STRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any Gcense or permit to operate a business if a person or company does not have a CertiScate of Worker's Compensation Insurance. THE ATTACHED STATE WOItKER'S COMPENSATION INSURANCE AFFIDAVTf MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES_� NO MO�'ELS AND OTHER LODGING ES�ABI�S��V3'$ - -- - ---- - - TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transiem occupancy shall be limited to the temporary and short term occupancy, ordinarilq 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 defitted 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 u' �spected by the Health Department�prior to opening. Contact the Health Departmem to schedule the inspection three(3)days pnor to opening.PL,EASE NOTE:People aze NOT allowed to sit m the pool area until the pool has been u►spected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,totsl colifotm and standard piate count by a State certi6ed 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 CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heaith I3epartcnent by filing�required Temporary Food Service Application foim 72 hours prior to the catered event. These forms can be o ed 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 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 We Board ofFIealth. OUTDOOR COOKING: Outdoor cooking� re aratioa or disnl�y of�n�foo�grQdu�t by�r�]Qrf�ds.-.^,�c�esr lic m�is pcohibite�_ NOTICE:Permits run annually from 3anuary 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15_2004. --_ ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR PO�L (i.e., PAIIVTTNG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND.�PPROVED BY Tf�BOARD OF HEALTH PRIOR TO COIvIMENCEMENT. RENOVATIONS MAY REQUTRE A TTE P DATE: I I �lJ_� SIGNAT ,i�/V�t/h "`� _ PRINT NAME&TITL : , 09/2S/09 ♦ a . � The Cammanwealth of MassachuseXts Department of Lndustriat AccideRis MlfeiNA�s bU0 Wnshington Shray 7`�`Floo� Boston,Mass. 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