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Home My WebLink AboutApplication and WC � d� TOWN OF YARMOUTH BOARD OF HEALTH F G'3C� 0 � � � APPLICATION FOR LICENSE/PE �tl� � �� .�x NOV 18 2011 * Please complete form and attach all necessary d " e � er l5 2011. Failure to do so will result in the return of '"` app icahon pa et. HEALTH DEPT. ESTABLISHMENT NAME: W O K � N- R OL L . � �� LOCATIONADDRESS:� � �/l � ,� Q/YI� TEL.#: � —��D � MAII.ING ADDRESS: A� � B I OWNER NAME: 60N . L� � CORPORATION NAME IF APPLICABLE : �}�I�ON C , MANAGER'S NAME: /1�)U�L �t9 TEL.#: � T D o2c`J MAII.ING ADDRESS: /3 ! +�4R/YI dU � POOL CERTIFICATIONS: I 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. I Pool operators must list a miniinum of two employees currently certified in basic water safety, standard First Aid � and Community Cazdiopulmonary 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 -CERTIFTCATIONS: I All food service establishments aze required to have at least one full-time employee who is certi£ied as a Food I Protection Manager, as defined in the State Sanitary Code for Food Service Fstablishments, 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. �. Yoox�� .�. �o�J � 2. PERSO_N_IN�I�ARGE: __ _ _ _____ __ _ _ _ -- _ _ _ Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operadon. �. YoOr�� ,Ce� ' a. I 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-chokuig 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 61e at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMTT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# _B&B $55 _CABIN $55 _MOTEL $55 � _INN $55 _CAMP $55 � _SWIMMINGPOOL $80ea ; _LODGE $55 _TRAII,ERPARK $105 _WHIRI.POOL $SOea FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LO-100 SEATS $85 Id�'�� _CONTINENTAL $35 _NON-PROPIT $30 _>]00 SEA1'S $160 LCOMMON VIC. $60 �a _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIItED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 j _<25,000 sq.h. $80 _FROZEN DESSERT $40 _TOBACCO $95 i NAME CHANGE: $IS AMOUNT DUE _ $ /S�S.on j *****PLEASE TURN OVER AND COMPLETE O'fHER SIDE OF FORMx+�#' � ( , + ADNIINISTRATION = „ Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth 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. AFFIDAVTI' 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 NO A44�#�.4 t41�9'!'�IER L�DGL`:G ES�ABLIS�NTS TRANSIENl'OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be lnnited 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 deFmed in M.G.L. c. 64G or 830 CNIIt 64G, as amended, shall generally be considered Transient. POOLS POOL OPENIlVG:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opemng. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE N01'E: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 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 gound swimming pool must be drained or covered within seven(7)days of ciosing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Depar[ment to schedule the inspection three (3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Departrnent 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.yatmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State cert�ed 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 untiLthe above terms have been met. OUTSIDE CAF�S: �atsidz- '.�., doar sexting-wid:waiter;�aitrEss s�ice};�:iust have prisr approva�fro�the Bsasd of Aealth. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service estabiishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII,ITY TO RE'Fi3RN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. Ai.T. 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 A SITE PLAN. DATE: �1 �� SIGNATURE: U PRINT NAME&TITLE: `�60n�47 �-�-0�lJ (��Q� Rev.10Y25/11 . , , � i� -� �'\ The Comraanwealth ofMassachusetts ',i � Deparhnent ojindnmial AcciJenu i N�aNrl�tlws �� 600 Washington Stnd, 7`"'F/ow . I ,Boston,Mass 02111 I Wohera'Compe�satiee Imm�a�n AiflQavit: . . . . . . .t .. . .., ,. ,. � . _ _ . . ... � �: �R oN Z�lc _ tctzaK -N - f�oz,� . ,. � �: _i3 r 9 , !n-AF+c! S?T--�-� . Y,e�mou�-f, .. I ��,� Smn: /YM� �o: oa66'��a �08- 760-�6� work sim�«aaw�rnu aamasx ❑ I am a homeoweer pedo:ming all wmic myseif. ❑ I am a sole poprietor and 6ave no a�e wockiog in any capeciry. �f I am an employer providiag workas'compea4ation for my empbyees wo�king m this job. eonQurme: �77N��1�f � :`�:�1�, ---.-�- .._. �t-.,=,_ �_ �:-_,:� a�»;.-t n s � -�-� _. ._ . . � , ._ _.�., . -. .�.: 13r9 . �t� �N �T_ �S�_ Y�ea, ouT�f ; �� oa66� �: �.: �o8-�Z6o- ae6a �.o„a�. C�an;�i2 �'fa�e ,�,8urarrce . �.� �coo99�70�0 ❑ I am a sote propcietor,ge�ersl te�trxMr,or looeeweer(e�rclt owe)aed have hirod the conl�acWcs listod below who have . 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