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Home My WebLink AboutApplicaton and WC . T�-PA-,�cgr.� M� .^� � TOWN OF YARMOUTH BOARD OF HEALTH _� APPLICATION FOR LICENSE/PERMIT -20 2 -�p11 ��d�D e,,,. ,� ffW! ,. * Please complete form and attach all necessary��3�i,_ y 17ec IS �JQl� 2 2 Q�� Failure to do so wIll result in the return of�jpur�tglicahf�ii pac �� HEALTH DEP�T. ESTABLISHMENTNAME: �j � 17Ar�oA�� M�►.� T ID• LOCATIONADDRESS: c► 5a �e.. - 41 S' yv.tim i� TEL#• C6�-3q$-4� Y MAILING ADDRESS: OWNER NAME: CORPORATION NAME(IF APPLICABLE): '�V� e Por iJ c.A x-s M/�,N� LY'n MANAGER'S NAME:nAqr ha�� . �—rt�l c TEL.#: o I- 0�3'✓ MAILING ADDRESS: �aY, S 3�1 �} s 70�✓ �! 02 41 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 certificauon to this form. l. 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 wpies of ' employee certifications to this form. The Health Department will not use past years' records. You must I provide new copies and maintain a file at your place of business. ! 1. 2. 3. 4, FOOD PROTECTION MANAGERS - CERTIFICATIONS: I All food service establishments are required to have at least one full-time employee who is certif'ied 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._�l's6� ce_A ��6o�-s�u�t�1 2. �J h h-, �IU.�� PERSON_IN CHARGE: _ _ _ _ _ ,. _ _ ___ __ __ ,, Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1. �� c�q �-rb o It� u 2. HEIMLICH CERTIFTCATIONS: 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-choking procedures below and ' attach copies of employee certifications to this form. The Health Department will not use past years'records. I� You must provide new copies and maintain a file at your place of business. 1. �)��e.�c y �--tr.d kJ b c,t�-cn 2. � h�I l'!t*yn, vti �, 3. /�h e kH�e Vl'k� _ 4. f�vr,�.,ir�. � 4 � RESTAURANT SEATING: TOTAL# / �L � h �"n"` m� �`�v� concmic: OFFICE USE ONLY LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# I _B&B $55 CABIN $55 _MOTEL $55 � _liJN $55 _CiliviP � $55 � -- _SWIIbLS�fLtifif'OOL $�'Oea. - _LODGE $55 TRAIi,ER PARK $105 ._WHIRI.p()pL . ggpey. .. _. - - . - _ _-.__�--` � . . . . ._. � FOOD SERVICE: LICENSE REQUIItED FEE pggMlT# LICENSE REQUII2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# _4100SEATS $85 _CONTINENTAL $35 _NON-PROFTT $30 1>]00 SEATS $160 ( 'I �COMMON VIC. $60 �-Osq _WgOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $SO I LICENSE REQUIRED FEE pEgMTf# LICENSE REQUIRED FEE pERMIT# LICENSE REQUIRED FEE PERMIT# _c50 sq.fr. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBpCCO $95 NAME CHANGE: $IS AM�UNT DUE - $ 220. p0 k****PLEASE TURN OVER ANB COMPLETE OTHER SIDE OF FORM+**'�i +' , ADMINISTRATION . 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 Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAV£T 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: f YES J NO MOTELS AIiTD OTHEY2 LODGIlVG�STABLiSHMEhTTS 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 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 diirry(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 shali not be considered transient. Occupancy that is subject to the collection of Room Occupancy Ezcise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENIIVG:Ail 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 pnor to opening.PLEASE NOTE:People aze NOT allowed to sit 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. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All 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 Yazmouth 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 obtamed at the Health Department,or from the Town's website at www.yannouth.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: . - - Otuside cafes(�.e.,-ei�tsloor seating wit�wait�r�waitre�s s?rvis�),�st�ve P=�..I�Y ��',• rh u,. ,��fu�.- --- OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food servix establishment is prohibited. NOTICE:Pernuts 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 15, 2011. Ai.i. RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEI. OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIlvIENCEMENT. RENOVATIONS MAY UIRE A STl'E PLAN. DATE: ��- '��1' �( SIGNATURE: PRINT NAME&TITLE: �� 1 G'L54t�.►- �' 0.��GN �l�� °L�� Aev. 10/25/11 _• � The Commonwea/th ofMassachusetts Department of Industrial Accidenls N�wN� 600 Washingtoa Smey 1"Floor Boston,Masc 0211I Workers'Compe�satioe Imvaece Aifldavk: . .� �. . . . . � . , tlw: pleue jR Ie�6H � � � � - � .. .. . - ::.� .._ ..� ��.. �: Th� �a �J uj ,�.-� w14,� , , . �: _ °C S a � ou�F�_._L 2 __ � � 1� ca.� m oa �s �M. M� �0. oz.(,�.�i �. .SD'� -35 e ti S 3�— � wodc siK�«at;on�ruu ad�essti -i.Ss- �Crs L� � i ❑ I mm a 6omoowner perfonniog all woik myself. �❑�(am a sole proprietor and 6ave eo one working in any capacity. � 1�i mm ao employerµoviding workeas'compeasati�for my anpbyees working on tLiy job. _ - : -_ry� _ __ - .. - _ . . camor.roe: '�Vlt�.. �.'(Uh Cb�L„� . \� loN� .L�:_ . : . _.. . . . . - -. . . _ . _ ad�e�s: � �� 1 Z� I cnv- ��.r,5"�l � Ik2mo '�1's ��- `08-�9�- �� I twa.rea.. 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