The URL can be used to link to this page

Home My WebLink AboutApplication and WC � � � TOWN OF YARMOUTH BOARD OF HEALTA �� _�� a r �� APPLICATION FOR LICENSE/PE 2012 k Y,��,l � ('i �, �' �.. � ,,;r . p�j40� * Please complete form and attach all necess�r}i��ent9 by Dec rnb T. Failure to do so will result in the retu�i.qf y appfication . ESTABLISHMENT NAME: P►1TrEk5 PA1LfFDISG IY�IU� Ga� TAX ID: LOCATION ADDRESS: TEL.#• 9 MAILING ADDRESS: �p��f� ��s -�— ��1{� 7 OWNER NAME: v�.S F�. 3,.I�.fLl,3�t CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: �F}vn� TEL.#�Sp�6 '7 4 D 3 aD MAILING ADDRESS: c ,9wte. 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 c�py of The cer[ific�tior.to this fonr,. l. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First 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 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 certified 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�le at your estabiishment. 1. 2. PF_RSON IN CHARGE: 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 establishments with 25 seats or more must have at least one employee uained 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 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. 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 _INN $55 _CAMP $55 _SWIMMWGPOOL $SOea. _LODGE $55 _TRAII,ERPARK $]OS _WHIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $85 � �(�� _CONTTNENTAL $35 _NON-PROF[T $30 _>100SEATS $160 _COMMONVIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KTTCHEN $80 � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _<50 sq.fr. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.fr. $80 .L FROZEN DESSERT $40 'Io� '�L�0 _TOBACCO $95 NAME CAANGE: $l5 AMOUNT DUE _ $ /Z S. 0 0 **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM+'**'�+ j . ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth 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 INSLIRANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED� Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS ANll OTHER LODGING ESTABLISFIMENTS 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 demonstrate 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 whiripools 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 prior to opening.PI,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 standazd 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 OPENIIVG: 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. 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�armouth.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: . • • �t,s.. � a . ..� ' .'1 _ T _J �C . . ..�'llll$i�JZI.-acJ�i.c.,GIIi�"ivIBc;it�i7�'tiv7tii:�'diiciiwatuwSJGivaCGj,iuu5�3'i8��ii.T r.v f."�2�IuZCLCT.aci�r ., . ....-.. ._ OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts 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. AI.L 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 COMMENCEMENT. RENOVATIONS MAY REQ IRE A STI'E P DATE: ��1I SIGNATURE: � PRINT NAME &TITLE: Aev. 10/25/11 . �� The Commonwealth ofMassachusetts Department oj(ndustrial Accidenls N�CaNrwstlqtlWs 600 Washington Street, 7`"F/oor Bostoa,Mass. 011l! Woricera'Compensatioo luaaranee Affidavih - . . E1anLtat li[e�aUa�: Pld�e PR�V'f krdWt natoe• c 1�� J(,�1� aaa�s-.Q�--��--—- --y—�—�,----/l— �, �W'�c � sm��: L`-�t-�T— �o:(1�.� U�,,�K �� 90 3� wodc sitc i atlon(futl add`essl: � ❑ I am a homeowner perFocming all woh mysclf. � ❑ I am a sole proprie[or ar�d have no one wocku�g in ariy capacity. � �I am an employer providing w compensation for my employees w g on Wis job. comin�v me: 1 ��4�—�(A.�7�.(j(eL � � i A. QT�T�lE-� .��,,: ` ( � R�� ciri' � . _._� 1 IVl ��;/� 3 oYaeeM• �� /�) �� u.�ro.��.�!_�'1)�a�l1,4 T �a Q (,S 7 �-d.t �/ _ �,-- � ❑ I arn a sole proprietor,geaeral coetraetor,or bomeowaer(ci�ele owe)and have hired the contractocs listed below who have tfie following workers'compensation polices: comwrv aaoe•� tldrar. �t�v: �x- tasva.ee co. owie.B wnouv vme: addF4�' cih• nYoee M• imea�ce eo. . �i.�.g . w�aw�r.rwer.rr� Failvc Y ueee pwr�e n rtq�4ed�tiv SecIM�2SA K MGL 152 eu kad b IYe h�lW�dvf�YY pmp�y�(�me�b f1,3KM�Ww oee ynn'�rhoameat n wy as d�1 peuMb la Ise fsr�ota 37'Ol WORK ORDEA ud�me KS10�.M a day apimt se. /mdene�d tW• capy ot t66 MaEeueW m�y be fxw�Nd b t!e Omce�[IwMlptlsr af�6e DIA far nven`e verlentlM. /Jo Aerrby certlfy r Me patns an ■ � ojprrjury�Y�e Ms feforwaHon prevJde!aboarla trre mif aemrt Si6�� Dste � �• � �' �.� � . PriM name P6oM N_il U O �q 0.�� 15c1a1 ox aWy do oM wrke�thy aro N he rnrpleled by tlly or 1�wp u@IeY� � . � tlly er town: petmM/Bceme i ❑❑'�e�E udeat ❑c4cdc iCimnemtt reapeme b d�ed �� '9 �Sekclmcsl bfBce ❑de+IN Dep��nf mmaati pv�oo: pYxe p; �p�e (mma s�mm�