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Home My WebLink About2008 License Application Packet �5 lG' !S� .�' �' -'"�y TOWN OF YARMOUTH BOARD OF HEA =� ° APPLICATIONFORI.ICENS � '' �` APR '2 4 2008 f , � s �. : * Please complete form and attach all necessary' oc�nts tiy r� � J EPT. Failure to do so will re�lt in the retum your applicaUon packet. NAME OF ESTABLISHMENT: YL r TEL. # .SDd'— 'r/62'35�� LOCATION ADDRESS: L ,n„ C ' MAILING ADDRESS: �� OWNER NAME: o..�N CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ./ � t✓ TEL. # 0 — — ,sjj MAILING ADDRESS: > � POOL CERTIFICATIONS: The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certiScarion to this form. 1. Z, Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Piease list these employees below and attach copies ofemployee certificarions to this form. The Hexlth Depsrtreent will not use past years' records. You must provide ne� copies and maintAin a fde 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 Protection Manager, as deSned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Piease attach copies of certificarion to this application. 'i'he Health Deparhnent wiU not use past years'records. You must provide aew copies and maintain a file at your estabGshment. I. !/Si�/ !//�+✓ Z P�RSQI*i iN CIiARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service estab6shments with 25 seats or more must have at least one employee trained in the HeimGch Maneuver on the premises at all times. Please Gst your employees trained in anti-choking procedwes below and attach copies of employee certifications to dus form. The Health Department will not use past years' records. You must provide new copies and maiatain a Cile at your place of business. 1. /��/ i�/��N 2. c(-sd� arLr-'u 3. //t, a nA F-� 4. %v�n a GW�� RESTAURANT SEATING: TOTAL # �,� ��' � �`' �� OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PER:�fIT* LICENSE REQL'IRED FEE PER4fl7 = LICENSE REQli1RED FEE PER�9T= _8&B S50 _CAB1N S50 _MOTEL S50 _INN S50 CA.1SP S50 SW'IYL�IING POOL 575ea � _LODGE S50 _TRAILERPARK 5100 ��'HIRLPOOL S75ra. FOOD SER�7CE: LICENSE REQUIRED. FEE PERIMIT ir LICENSE REQL'IRED FEE PER14ilT� LICENSE REQti1RED FEE PER.VIlT= �0.100 SEATS 575%� 08^�Zcj _CONTINENTAL 530 . �_NON-PROFIT� . S25� _>IOOSEATS SI50 YCOVLbiONVIC. S50 �D –$ (O�o _WI�OLESALE S75 RFTAIL SERVICE: —RESID.KITCHEN S7i LICENSE REQL7RED FEE PER'bffI= LICENSE REQL4RED FEE PER�II?= LICENSE REQUIRED FEE PER�DT= _<SOsq.ft. S45 _>2i,000sq.R. 5200 VENDI'.�G-FOOD 5?0 _<25,OOOsq.B. S75 _FROZENDESSERT S3i �✓ TOBACCO Si0�037 va:�c�vGE: sio AMOU:�T DUE = S � 75 """"�pLEaSE T1:RY OYER�\D CO�iPLE'IE OTHER S1DE OF FOR\i'"""* � � 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 Worke.r's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION IN$URANCE R AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be pa�d prior to renewal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the liroitat�ons of Motel or Hotel use,Transient occupanc.y st�all be limited to the temporary and short term occupancy, ordina�lY and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate t6at they maintain a PcinciPal Place ofresidence elsewh�e• Transie.nt occupancy shall generally refer to continuous occupancy of not more than thirtY (3�) daYg. and an aggegate of not more than ninety(90) days within any si�c(6)month period. Use of a gu�t unit as a residence or dw,elling �nit shall not be considered transient. Occupancy that is sublect to the collection of Room Ocaiipanc,y F�ccise, as deSned in MG.L. c. 64G or 830 CMR 64G, as amended, sLall B�allY b��°�d��Traz�aaent. * NOTE: Enctosed Motel Census must be completed and returned w�w tt�apphca�on• rooLs POOL OPENING: All swimming,wed'u►S and whirlpools which have beet►c(osed for t6e season mus�fi � �� by the Aealth Department prior to opening. Contact the Heaht►Department to schedule tt�iaspect► prior to opening. POOL W ATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate couoc by a State certified Iab, prior to opening, and qnarte►1Y thereatter. POOL CLOSING: Every outdoor in ground swimming Pool must be drained or covered witFtin seven(7)daYs of closing. FQOD SERVICE CATERING POLICY• Anyone who caters witttin the Town of Yazmouth must notifY the Yarm°uW Heakh Depa�t�at b3'filin8�� Tem rary Food Service Application form 72 hours prior to the catered evem. These forms can be°b�a�� Heal h Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified�ab. Test results m°st be se°t to the H Department. Failure to do so wi11 result in the suspens�on or revocation of your Frozen Dessert Permit uadl the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating w►th waiter/waitress service)>must have prior approval from the Board ofHeaith OUTDOOR COOKING: Outdoor cooking,Preparation,or display of any food product by a retail or food service es�tab��shme�►t is Pr°hi6ited• NOTICE:Pernrits run annuallY from January 1 to December 31. Tf IS YOUR RESPONSIBII.PIY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISFIlvIENT, MOTEL OR POOL (i.e-, PAINTING, NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTIi PRIOR TO COMME:�tCEMEVT. RE�IOVATIO�IS MAY REQUIRE A SITE PLAN. DATE: � 2 J SIGNANRE: � � A�� n �� PRINT NAME&TITLE: ,,: ,�,r�� ,o TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERM[T NUMBER: #08-175 FEE: 75.00 [n accordance with regulations promulgated under authority of C6apter 94,Section 305A and Chapter I(1, Section 5 of the General Laws,a permit is hereby gianted to: Bill Moran, 62 HiRhbank Road South Yarmouth MA Whose place of business is: Bass River Grille Type of business: Food Service To operate a food estabGshment in: Town of Yarmouth Permit expires:_ December 31. 2008 aonitD oF HEnLTH: ,�$�/E �„�r,� � SEATING: 73 � � ,�;,� v� �� REsi2ICTroHS: Disposable Service(fily. f� 3.�� Qu�✓l..N Apri129.2008 � nice G. utphy, , R.S.,CHO Director of Health THE COMMONWEALTH OF MASSACHUSETTS TOW�I OF YARMOUTH PERMIT NUMBER: #08-t06 FEE: $50.00 This is to Certify that Bill Moran d/b/a Bass River Grille at Bass River Golf Course 62 HiAhbank Road South Yazmouth MA IS HEREBY GRANTED A COMMON VICTUALLER'S LICENSE [n said Town of Yarmouth and at that place only and expires December thirty-first 2008 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting the licensing of common victuallers. This license is issued in confornuty with the authority granted to the licensing authorities by General Laws, Chapter 140, and amendments thereto. In Testimony Whereof, the undersigned have hereunto affixed their official signatures. BOARD OF HEALTH: 3Eefe�e Sllal�., 52.N., C'/laixntun sEnrr.vc: �� C.haxlee 3E. .7Cellillex 41ice C'Ilaa�v►tan .r�e 3. .��, el� CGuc (�een6aum, J2.N. £ueP,�e �. 3fsryaa Aori129.2008 Bruce G. Mwphy,M .,CHO Director of Health P . d THE COMMONWEALTH OF MASSACHUSETTS TOWN OF YARMOUTH BOARD OF HEALTH PERMIT NUMBER: #08-037 FEE: $50.00 � Tt�is is co cen;ey u,ac Bill Moran d/b/a Bass River Grille 62 Hiq,hh n�ac� 4oL h Y rmo rth MA IS HEREBY GRANTED A LICENSE For SALE AND DISTRIBUTION OF TOBACCO PRODUCTS AS PER THE YARMOUTH BOARD OF HEALTH TOBACCO REGULATION This�er�s�aut�iq2�fortnit�with Article VI f e Sani�Code of The Commonwealth of Massac6usetts,and exp s r er un sooner suspen�or revo e . Apri130.2008 BOARD OF HEALTH: ,`�¢(¢ft $�� .� �qiNfllqlt �¢O .�. :�l�16� �ICC �p4YI1lafL �PXf �. BKUlGIL� UAJIlIF Q��f�l�K/��,,IfC¢f1�(!lI/K� �.,/V. """"!►"�• .`�EQ�(.PA Bmce .Murp y, . , � Director of Health '^ �.S S �Z...r� ��P Crw(�S� Apri115, 2008 To Whom It May Concern; The following persons have successfixily completed a course in the Heimlich Maneuver, used for the choking victim, adult and child. �i .�i/i�',�i�'I/lA/(..� .�� is1 �e IY' "-' i � < T ank you. ti � + Sheila Glynn AHA Instructo � e� g �� r m O �9% � A � m � ��' m O �gndw � m rn o f m j H �3� 'm � co�S� r* ogwm. r1 �o8m L+ o`c?v n v3 < � Po�m � _ . � 05'�'a5� � ' m yFh o N 3 y 30 �yma � in ''{1�' ' � o � � N P ' �n o fOi m 'om��5y � �W o m p " p R �3�q n .� N 3 � � e '�' i.�. °�