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Home My WebLink AboutApplication and WC . B�acK S��P �� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-20,�0 �� * Please complete form and attach all necessary documents by�ecember 1 S 9. Failure to do so wiii resuit in the retum of your appliGarion pac et. _ „ , y; NAME OF ESTABLISHMENT: C S�n.r �( TEL. #I?�F.��2 -SZY1� LOCATION ADDRESS: r MAILING ADDRESS: .v.ur a- 0.2 .7 OWNER NAME: r . Lz,�dT FE or s � CORPORATION NAME (IF AP LI ABLE): � , C.T,.*�f -T,�c MANAGER'S NAME: G��eS (,.��Cr� S.cc TEL. # SZ��J 77/ S"/UZ MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pooi pperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to ttris form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee certificarions 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 business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protecrion 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 mauttain a file at your establishment. 1. C✓(hs. (...�e-��r�e ��ToS,N 2, Jtl�... L�'t2'{'f PERSON IN CHARGE: - -- Each food establishment must have af least one Person In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats ar 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-chokuig procedures below and attach copies of employee certificarions to ttus fo�n. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ��S ��l�OTt 2. 3. C� S 4. RESTAURANT SEATING: TOTAL� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# L[CENSB REQU[RED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL S55 _INN 355 _CAN3 S55 �,SWIMMINGPOOL S80ea. _LODQE $55 _7RAII,ERPARK $105 _WIIIRLPOOL SSOea. FOOD SERVICE: LIG£NS$REQUIltED FEE P�RMIT# LICENSE REQLJR2ED FEE PERMI2# LICENSE REQUIRED FEE PERMTI# I 0-100 SEATS S85 �'f/0-6�I�i _CONTINENTAL S35 NON-PROFIT $30 `>I00 SEATS $160 �COMMON VIC. $60 -}�(�S� �WHOLESALE 880 RETAII.SERVICE: —RESID.KITCFIEN S80 LICENSE REQUIILED FEE PERMIT# LICENSE REQUIRED FEE PERMII'# LICENSE REQiJIRED FEE PERM[T# _<SOsq.ft. $50 >25,OOosq.ft. 5225 _VENDING-FOOD 825 _Q5,000 sq.ft. $80 _FROZEN DESSER? $40 TTOBACCO S55 � NAMECHANGE: $15 AMOUNTDUE _ $ I�SAO ••,"«pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""• \ ADMIlVISTRATiON 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. TH� ATTACHED STATE WORKER'S COMI'ENSATION INSURANCE . AFb'IDAVIT MUST BE COMPLETED AND SIGNED, OR '� CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior o renewal or issuance of yow permits. PLEASE CI�CK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limita6ons of Motel or Hotel use,Transiern occupancy shall be limited to the temporary and short term occupancy, ordinazily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maiatain a principal place of residence eL4ewhere. 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 wirich have been closed for the season must be ins by the Fiealth Department prior to opening. Comtact the Health Departmem to schedule the inspection three(� pnor to opening.PLEASE NOTE: People aze NOT allowed to sit m the pooi area until the pool has bcen inspected and opened. POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total coliform and standard plate coum by a State certified lab, and submitted to the Health Departmern 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 norify the Yarmouth Health Department by Sling 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 approvai from the Board ofHeahh. OUTDOOR COOHING: Outdoor cooking,preQarariog_or di�lay_of any food product by a retail or food service establishmern is p_rohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILdTY TO RET'URN Tf� COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINfING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TFIE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE UTRE A SITE PLAN. DATE: �� /�� O� SIGNA �� PRINT NAME&TIT E: �I��=s ' L'`"'�}r�'�J' �� osnsiov PRODUCER THIB CERTIFICATE 18188UED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE erydan 6 Sullhren Insurence Aaency Inc HOLDER. THIB CERTIFICATE DOE8 NOT AMEND, EXTEND OR BB Felmouth Rd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Hyennls, NV►2@01 COMPMIIES AFFOItDINO INSURANCE COMPANY A GRANITE 8TATE IN8URANCE COMPANY IN8URED Jamas A Lledls Ina 84 Rocky Rldge Raed Dennk,MA 02838-0000 THIS 18 TO CER�IFY THAT THE POLICIES OF IN8l1RANCE L18TED BELOW HAVE BEEN ISSI�D TO THE II�URED NAMED ABOYE FOR THE POLICY PERIO�INOICATED,NOT WITHSTA�ING AN'f REDUIREMENr,TERM OR CANDITION OF ANY COMRACT OR OTHER OOCUMFM WRH R68PECT TO WHICH THIS CERrIFlCATE MAY BE ISSUEC OR MAY PERrAIN,hIE INBURANCE AFFORCEO THE POLIGES DESCPoBED HEREIN IS SUBJECT TO ALLTHE TERMS,FJOCLl1810N8 ANO CONDRIONS OFSUCH POLICIES.LIMITS SHOWN MAY H4VE BEEN REDUCEO BY P/UD CLAIMS. � L7R MC Q NAlMNC! �0.10RNUY!!R �pJQI'lRLOiN!OAl! �pJ67l1PM110N D117! A OENPLOVERS'LWAIfY LIMITS E PROPRETORI rxn�eas�o�curnre OFfIGERBARE Haoox�❑ 7423771 3/08t2009 3/08I2010 ANTORYLWRS aaepa Apptiv to NA OparaCm�Or}t. XACCICENT S �0,� ISEABEPOLICYLMAR $ L00.00 18EA8EFACX EMPLOYEE S 000, DEBCIiIP710N OF OPEMTIDNSNEHICL68lSPECW.tiEMB CERTIFICATE HOLDER ANCELLATION TOVYNOFYARMOUTH BXOULDANYOFTXEA90VEDESCRREDPOLICIESBECANCELLEDBEFOIiETXH E7�PATpN MTE TXEM1EOF,7XF 168UNG COMPANY WRL ENDEAVOR TO IMR]Q 1148 MAIN ST OAVS WRIREN NOTICE TO TME CERTIFIGTE XOLGER NAMED TO7XE LEFT,BIlT SOUTHYARMOUTH, MAOZBB4 FAILURETOMAILBUCXNOTICEWIALLIMP08ENOOBLIGA710NORLWILIiYOF FNY NIND UPINI T1E COMPANY,ffS/tGEN780R REPRESENfATNEB. AUlHOfiIZED REPRESEMATNE r �,�.-.,��' �