HomeMy WebLinkAboutApplication and WC .` � TOWN OF YARMOUTH BOARD OF HEALT� - , G3��l�DD
APPLICATION FOR LICENSE/[jE'RMI�T=2 0
��'��1�� . DEC 0 91Q09
" Please complete form and attach all necessary do t Dec er I
Failure to do so will result in the retum of your applicat�on pa Utr� .
NAME OF ESTABLISHMENT: J7 An�GcLn G RILL�� �'/{.vol.✓/cfF-�s TEL. # 9 �ZZZ�
LOCATIONADDRESS: /Z4'7 /yJa,.+ sT au�H it ror, G "
MAILING ADDRESS: 3 / L.�-K�- !td c e ,t r a J ; / ,f �°`��
OWNER NAME: t�iw�� � e� D F6IN or SSN);_
CORPORATION NAME (IF APP ICABLE):
MANAGER'S NAME: S'Co tf �/=.��`Y2c TEL. # S3 9— U S//
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certitied as a Pool pperator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the cenification to tivs form.
1. �� 2.
Pool operators must list a minimum of two employees currently certified in basic water safety,standazd First Aid and
Comznuniry Cardiopulmonary Resuscitarion(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.
l. �� 2.
3. 4.
FOOD PROTECITON IvfANAGERS - CERTIFICATIONS:
All food service establislunents are required to have at least one fizll-time employee who is certified as a Food
Protecrion Manager, as defined in the State Sanitazy 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 maiatain a file at your establishment.
1. �Go2`f ��.En.a,co 2.�/F��C�A /�/�,CG.�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. Se�� f�rrin/�n� , G�nc�es YN9 4/nGdn, 2. �A�<FGI/� /�f�lf�,✓,'L/7?lINAGFi�
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-chokuig 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 51e at your place of business.
i. l✓� - i.
3. 4-
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQiIIRED FEE PERM[7# LICENSE REQUIRED F6E PERMIT#
B&B $55 _CABIN $55 _MOTEL $55
INN $55 _CAIvLn $55 �SWIMbI1NGPOOL $80ea.
LODGE S55 _TRAILERPARK $105 _WAIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED F$E PERMIT# LICENSE REQUIRED FEE PERMIT ti
I 0-100 SEATS �85 —OS� _CONTINENTAL $35 _NON-PROFIT S30
>100SEATS SI60 / COMMONVIC. $60 @�O� _WHOLESALE $80
RETAII.SERVICE: —RESID.KITCHEN S80
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# UCENSE REQiJIItED FEE PERMIT#
_<SOsq.ft. S50 >25,OOOsq.ft. 5225 _VENDING-FOOD S25
�QS,OOOsq.ft. 880 _FROZENDESSERT $40 _TOBACCO $55
NnME c�nxGE: $15 AMOUNT DUE = S /�S.OO
••••«pLEASE TURN OVER APID COMPLETE OTHER SIDE OF FORM•""•"
:� . . .
ADMINISTRATION - '
Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any license or pernut 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 taxes and liens must be paid prior to renewal or issuance of your pemrits. PI.EASE CHECK
APPROPRIATELY IF PAID: ' /
YES !� NO
MOTELS AND OTHER LODGING ESTABLLSHMENTS
TRANSIENT OCCUPANCY: For pwposes ofthe limitations ofMotel 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 OPENING:All swimming,wading and whirlpools wluch have been closed for the season must be insp�
by the Health Departmentpnor to opening. Contact the Health Departmem to schedule the inspection three(3)days
pnor to opening. PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has baen inspected
and opened.
POOL WATER 1`ESTING: The water must be tested for pseudomonas,total coliform and standard plate couat
by a State certified lab, and submitted to the Health Deparcment three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('n days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must norify the Yarmouth Heaith Department byfiIw�the ed
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained�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 Pe�mit 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 ofAealth.
OUTDOOR COOHING:
Outdoor cooking,prepazatioq or dispiay of any food product by a retail or food service establishmern is prphibited.
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILI7'1'TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
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 REQUTRE A SITE PLAN.
DATE: L 9 SIGNATURE: i/
PRINT NAME&TITLE: �f1�� � 'c ,�,,, r �
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09/25/09
� .. � The Commonwealth ofMassachusetts
Departmeat of IndusTrial Accidents
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600 Washington Street, �a Floor
Boston,Mass. 02I11
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