The URL can be used to link to this page

Home My WebLink AboutApplication and WC ` TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMiT.-2010 �l � 3 ?0�9 p,��} � �o *Please complete form and attach all necessazy docume��i sf by Dbec �Z T��r� . Failure to do so will result in the retum of yaur application . ¢ NAME OF ESTABLISHMENT: � , TEL. #Sb`6 77� �35� LOCATION ADDRESS: m MAILING ADDRESS: vk � A-r.�rJ s � i D3 � OWNER NAME:��YV�gS � f-�l.fLl-�1.1 TAX ID (FEIN or SSN1� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:��n F_ TEL. #�G� 75 0 ?,y�o MAILING ADDRESS: �Prrn S 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 form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standazd First Aid and Community Cazdiopulmonary Resuscitation(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 Gle at your place of business. 1. 2. 3. 4. FOOD PROT&CTION 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 tlus application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food esfablishment 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 trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokwg procedures 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. L 2. 3. 4. RESTAURANT SEATING: TOTAL # �Z_ OFFICE USE ONLY LODGING: LIC�NS£REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL %55 ,�INN $55 _CAMP S55 �SWIMMINGPOOL $80en. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQL7IRED FEE PERMIT# I 0•100 SEATS S85 �� _CONTINEIV'IAL S35 _NON-PROFIT 830 _>I00 SEATS $160 _COMMON VIC. $60 �WHOLESAL� S80 RETAQ.SER�'ICE: —RESID.K[TCHEN S80 LICENSE REQUIILED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LiCENSE REQi1IltED FEE PERMIT# _<SOsq.B. $50 >25,OOOsq.R. 5225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 �PROZEN DESSERT $40 �OQ3 TOBACCO $55 xnMEcaax�E: sis AMOUNT DUE _ $ I 2S .00 "*"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*�** ADMINISTRATION ` Under ChapYer 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 INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid pri to renewal or issuance of your pemrits. PI,EASE CHECK APPROPRIA'I'ELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotei use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotei use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresidence eLcev✓here. 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 sha11 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 OPENING: All swimming,wading and whirlpools which have been closed for the season must be insp� by the Health Department prior to opening. Contact the Fiealth Departmem to schedule the inspection thrce(3)days pnor to opening.PLEASE NOTE: People aze NOT allowed to sit m 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 certi8ed lab, and submitted to the Health Department three (3) days prior to opening, and quazterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(�days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters wittrin the Town of Yarmouth must notify the Yazmouth Health Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtazned 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&om the Board ofHeakh. OUTDOOR COOHING: Outdoor cooking,prepararion, or display of any food product by a retaii or food service establishmem is prohibited. NOTICE:Pemvts run annually from 3anuary 1 to December 31. TT IS YOUR RESPONSIBII.I1'Y TO RET[IRN T'HE COMPLETED RENEWAL APPLICATION(S) AND REQiJIlLED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��'� "�� SIGNATURE: � l �� PRiNT NAME&TITLE: — ; 0925/09 _ � The Commonwealth of Massachusetts Department of Industrial Accidents NNuNb� 600 Washington SdeH, �"FJoor Bostan,Mass. 02I11 Workers'CompensaHon iesorance AtCdavih Baiidiog/PlembinglElectrical Coatrsetors AQRlitaat faformnb�- � � Please�_INT ke161� � name- �'`"JYL'1�S f— 111A� �.F�.i1 aaa,�s: C> �c�� {�b � � c� �t�-f ILJ A)1 L CB�� state• �>`"r. . -P. lbyo ' r ohoce# �� l U �"�W work site loca[ion(full addmssl- � ' 1 I �-�1�� T � � � � �'��17'1 ('fl.t�' {n (� � �� ❑ I am a homeowcer perfocming all wock myself. Project Type: ❑New Constn�cti�QRemodel ❑ I azn a sole propnetor and have no bne working in any capacity. ❑Building A�lition �"1 am an�ployer provid'wg workecs'comp1ensation for my employees wodcing on Utis job. comomv nme: �I�.f��%��S tJ��-��"C�`.�e� t / 1 1 l� � ��l-C� _ �� 1 T . .a��.: 1 \ cl I� �t"c✓. -�-�b �a: �.-V l�t��v�c-;i., � L�( �� a; 4��6 `)7 I � S u -b T,— v.�,.«�. �`� i c a�, r-� i�_�-�c�-1- �� 9�j �'7 L 0 9� o�i .. �... � � �.��.;.x� : ❑ I am a sole proprietor,8eaerat co�ttactor,or homea�vaer(circle one)and have Liced the contrecto�s hste�l below wlp have� t�following wo�kecs'compwsation polices: � comm.v ome. . . ' � . .. � . . . ad�as• .. . . . . . . . clh: � . , � . . � �� orwe8• . . .. . . . . � . mmaxe ca - . �� . � . . . _ . . .,.� . .., . .. . _. ... .. . ... a:"rt . ., �i�me• addrns' � . . _d�: � : . . .- . . . . . . �R-. . . . . � � . . . . ._ . . �, _ _ ,_- . - - - - - - _ _. _ . _.. .S . ._.__ �. _.__ . ._ .. .-- - -_ . . :,. . :. ... . . , .�t„ . :-_. . , ';_ .:-, .,�`:.a_� r _. �:i�YF 7 +^A. .". ,�.,. tAG'�'ixW;, t� ,` FaYoe Y secue orc��e n rtq�6N oJQ Scelb�iSA KMC.L LS2 eu kad d IYe��f ai�ioal peape da fee�p b S4TM.N uNw ••�m�+'�.r�«d�...Re..aw�mu�u�.r.srorwowcoxoee..a.e�esiaa�eaa.y.�c.�. i�.amu, capyNWaOa�oryEefonr�rdedMNeO�eNLv�ofHeDlAfxa�agevrtl8ntler. - . � . -. . / /fo 6areb ^ Jlp dNv 9�Pn7+�T N�af tAe iwfwwdon proeiAel�box h lrne�ad cemce . . yceitrjy j'lerNYe petnsaw �s� �/ �/—� � �i: � �a l l-`� -�j r�� 1 < _" � t�—rZ� �� Peo�n � �>�b��i�� tiL�i� �� .�ew.ae wy au eN.rrke d td..re.a ee c�Wefcd 6r.dlr.r w..�.m�f.�.. . . � . dty ar bwa: .. ..@��8 1-lttoante.p� t ❑eht�Kimst�&reapeme b rtqartd . - � .. �� . . �'s O�oe . . � �llnMk U�l l��' i; 1-4YA`