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Home My WebLink AboutApplication and WC ��^� �� TOWN OF YARMOUTH BOARD OF HEALTH � � _ _. � APPLICATION FOR LICENSE/PERMIT-2011 �I * Please complete form and attach a11 necessary doc��b�Dec� e EF ✓ Failure to do so will result in the return of;your �p�ication p _ . ESTABLISHMENT NAME: U. � 1 � I - Lf� TAX ID: LOCATION ADDRESS: TEL.#: 1 3 �{ MAILING ADDRESS: Za / OWNER NAME: CORPORATION NAME (IF APPLICABLE): �-- MANAGER'S NAME: � TEL.#:� (�3 OZ� MAILINGADDRESS: '' �; .�-�G,�7 POOL CERTIFICATIONS: The 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 certification to this forni. 1. Z Pool operators must list a mn�imum of two employees cun•ently certified in basic water safety, standard Fn-st Aid and Conunwiity Caz-diopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this fonn. The Health Department will not use past �ears' records. You must provide ne�� copies and maintain a file at y�our place of business. 1. 2 3 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislvnents az-e requued to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined 'ui the State Sa�iitaiy Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past pears' records. You must provide new copies and maintain a file at y�our establishment. I. 2. PERSON IN CHARGE: Each food establisiunent must have at least one Person In Charge (YIC) on site during hours of operation. 1. 2 HEIMLICH CERTIFICATIONS: All food seitiice establislunents with 25 seats or more must have at least one employee ri•ained 'vi the Hennlich Mazieuver on the premises at all tunes. Please list yom• employees tranied in anti-chokine procedures below aud attach copies of employee certifications to this forni. The Health Department will not use past y�ears' records. You must provide new copies and maintain a �le at your place of business. l. z 3. 4. RESTAURANT SEATING: TOTAL # C� LODGI\G: OFFICE USE ONLY LTCENSE REQUIRED FEE PER�fII'� LICENSE REQUIRED FEE PER\4IT" LICENSE REQUIRED FEE PER'�III'= _B&B S55 _CABIN S55 _\10TEL SSS .. —� ��= CA,�4P — S�� _Slti\-IIvfl�iGrGOL SBGea. _LODGE S�5 _IRAILERPARK SIO� ��Z-IIRLPOOL S30ea. FOOD SER�'ICE: LICENSEREQL'IRED FEE PER\41T= LICENSEREQUIRED FEE PFR\�IiT= LICENSEREQUIRED FFE PFR\41T= I 0-100SEATS � SSS �(I-Q37i _CONTINENiAL S�S _NON-PROFIT S30 � _>100 SEATS 5160 _C011\40N�'IC. S60 _RZ-IOLESALE S80 RETAIL SER�7CE: —RESID.KIiCHEN SSO LICENSE REQUIRED FEE PER�iIT= LICENSE REQUIRED FEE PER\417- LICENSE REQDIRED FEE PER\41T� _<50 sq.8. S50 _»5,000 sq.it 5229 _t'ENDII•iG-FOOD S25 _QS,OOOsq.A. S80 I FROZENDESSERT S40 ��O _TOBACCO S55 �.��iE cx��cE: sis ANTOUNT DUE _ � �25.0 """`"*pLEASE TiR\O�"ER A\D CO�IPLETE OiHER SIDE OF FOR�I"*•^* � , k • ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewa] of any license or pernvt 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 COMPLE'I'ED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTEL•S AND OTF3ER LODGiNG ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMote]or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with mote]and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transient occupancy sha11 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in MG.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 inspectionthree(3)days pnor to opening. PLEASE NOTE: People ue NOT allowed to srt m the pool azea until 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. YOOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7) days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Al] 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 Yarmouth 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 DepaRment, 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 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 Pernvt until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'P TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S) AND REQiJIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUS'T BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIviENCEIvfENT. RENOVATIONS MAY REQU E A SITE P AN DATL:�� pZ� /D _ SIGNATURE: � � `� _ PRINT NAME&TITLE , � 10-06 70 - , , �., \ � The CommonweaJth ofMassachusetts � Deparnnentojlndustrin/Accidents N�IeiNi�q� : 600 Washington Street, Y'�F[oor ' Boston,Mass. 011ll Workers'Compensation Imarance Aftidavih Baildi�/Plombinp,/Ekctrical Contrac[ors � Auolka�t fifa.matln• Plea�e P[L�1'kaaM. n�: ,'`A�w. S F t�-1-i�t.fL,L�'�L� a_ddress__� ._v --[yC.LX. -.f-`-�__ /� 7� __.____ ll l� / � c-��c � ---7[� :�T ciN �1)�� S � . . �/ _-_.__ -__-.—___—.—_.. � state r o � hhone#��l J75 L /l��yc+� Y work site loca[ion fiill address: ❑ I am a homeowner per{omting all work myself. ^Pro'e T ❑ I am a sole o 1 YPe� ❑New ConsWc[ion Remodel � pr prietor and have no one working in any capacity. �Building Addition (29�I am an employer providing worke�s'co(m�pensatioo for my employees wodcing oa this/j�ob. � cnmwar aamr �(,1,s�'��- 1 l`'F6 f�-�� .G '�� V � t V v I T . addras: � 1C'1 �/ �P �!\ � ci : J ,. , � �r M Trl �'l.. \V 117-� V c�-(� 7 � ..hoe�M L�� D � � � � � � Immaxeca /. r/G - �ryv� 1 (�Qy� �i..�# �Q �L- D�� ❑ [am a sole proprietor,geweral coetrxtor,or homeawner(cire(e oneJ and have hiled the co�tractnr��y��a�,µ,��Ve the following workers'compensa[ion polices: ro e: ddreaa• ctry: ohoee q ieamaxe ca M � addraa• c�: oYa.s N immsae,et�y,. . ._. . . . _. . .... ATheiY�Y�qr�ees�rr k F+1Are b scme w°en�e a rtqdeed sedQ Seetle�2SA ef MGL 152 eu Ind b 1Ye IaysAlY��fetsld �ynn'Impriwmeet as we�a dH peaapin In�se ters of a STO�WORK ORDER aed�aee ef SIOO.O�P�MIn d�ane�p a f1JM.0�a�Al�r npy a(Hi�Maoeeent m�y 6e fnrwirded m tAe Oeke ef Iwestlptl�m of We DIA for tv�erate v�NetatlN. Y��°'�me. 1 mdmhad tl�1 a /dn hereby certlfy un e fAt pa�w.r ond pene oj rfyry at N�e iwjorme(!on provJdeAaboat&bye m'd rorrerC Signalure Date �.�-�. � Print n � 1 ri l..C� ` Phone# (� � n(fiNd u�e only do nW wrl[e 1�Ihh area b De eeaPltted by d(y or bwn o@Ici�� ... . . . . . . Nty or tawp� M��/lkeme N QBoidh�6 Depar�ent ❑cnedc rc(mmem,6e,e�p,me is.zymrea Oucee+ioS eoa.a rno/aef penoo: OSdtttmeeS(MBee c .me".yi mm� PAose A; ��Wrdcat v