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Home My WebLink AboutApplication and WC . -r' D`Hn�c-61r C�iu.�e � TOWN OF YARMOUTH BOARD OF HEALTH SAnr�;�c.tl3�, , �� APPLICATION FOR LICENSE/PE I �= • � °' / /n * Please complete form and attach a11 nec�ss�ry , Ace �i�r 7� ZD�. � � Failure to do so will result in the r�tuin o tius�li"ah n p tl'H DEPT. . :.s ESTABLISHMENTNAME: `.9N6cC0 G�/LLEP y�o /cyJ T / LOCATIONADDRESS: /Z�7 /f1//i�J ,STr our.� /�.cMoNrJ> az6dy TEL.#: S;3h'-37�1-zZZ7 MAILINGADDRESS: 3S�/ L4r-E C'ifa�t� D/r � m,4RSTorr11J9i«s , //1� cJ265�� E-MAIL ADDRESS: L / T 5 e L•ca OWNERNAME: ,4ut ll �c.Fsz CORPORATION NAME (IF APPLIC`�LE): L jS T/ss �oo CE.Cri tc .Zii� MANAGER'S NAME: SGa N /5,�.�d.4ac0 TEL.#: MAILING ADDRESS: 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 tkus form. 1. 2. Pool operators must list a miniinum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their 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 are 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 file at your establishment. 1. �� Rn�n� 2. /`�t/!fr //ia'�9h/ PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 7Go// i�t/G�!/in� 2. .9IH/J �ti/��✓ ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certifica6on to this application. The Health Department will not use past years' records. You must provide new copies and maintain a 51e at your establishment. l. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich Maneuver on the premises at all times. Please list yow 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 REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 � CABIN $55 MOTEL $55 —INN $55 CAMP $55 SWIMMINGPOOL $80ea �,ODGE $55 _TRAILER PAI2K $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# J_0-100SEATS $85 #!�f-UN,�� _CONT[NENTAL $35 NON-PROFIT $30 >I00 SEATS $160 LCOMMON VIC. $60 �'y _WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQU[RED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 � AMOUNT DUE _ $ I i{S ,Q C� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****' r_ -. 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 Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR / CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: , / YES V NO MOTELS AND OTHER LODG�NG ESTABLISHMENTS - - __ __ _. --- -____._ . _ 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 customazily 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 ofnot more than thirfy(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 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 inspection three (3) days prior to opening.PLEASE NOTE: People aze 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 standard 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. _ ____ _ _ _ FQ(JD SERVICE - SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Departznent prior to opening. Please contact the Health Deparhnent to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Deparhnent 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.varmouthma.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 ofyour Frozen Dessert Perxnit 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 of Health. OUTDOOR COOHING: Outdoor cooking, prepazation, 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. ALL 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 REQUIRE SITE PLAN DATE: D 3c 3 SIGNATURE: �� v , �j�,��„-T-- PRINT NAME& TITLE: �,r}u � L� /�F,'G/CeiG ��n�„��' Rev. 10/08/13 16128l2013 12:56 508-540-9255 DFM IN5lJR�JC� PACaE 01!@2 a CERTIFICATE OF LIABtLITY INSURANCE iolae/� THIS CERTIFICATE IS ISSUBD AS A MATi'ER OF IqF6RMAT�ON ONLY ANO CONFERS HO RK�IMTS 1�0�1 TFIE CERTiFlCATE H�.06R•TXIS 6FlOM�CTXSDCERiIiiCA OF�iM3URANCE OOES HOT C�1877MH A�CONTRACTT��TW�EEI'1 THE ISSURIGRI�ERER{81.TMVTFlORIgD REPR6SENTATYE OR PROQUC@R,AND TI#CERTIRCAT£FI��ER. 1MpOR'PANT: N Mo aartlficaEs hold�it is M ADDRIMtlAL IN6UREA.the Po�Y(�)most W MQOreUA. N SiJBRO0A7WN IS iIYAIYED,s�ad Su tha Nrms a�M eondN�na of the poflcY.c�M Po�kNa nMiY roQu�+s an�dorsemerd. 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