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Home My WebLink AboutApplication and WC � � ��a-� t��auar.�mgN � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-.2011 � � �C�1c:-l�l�b.� DEC 2 ?��10 * Please complete form and attach all necessary docyments by Ilecember 15 2 Failure to do so will result in the return of ybur application pac et. ESTABLISHMENT NAME:�e p�s�A 1� 1•�A � ro TAX ID� LocaTtorr aDDxEss: q S 2 R6.2,-r� 25� S /.��+�, .-t1d� TEL # 5�3 3qg -q� 't� MAILING ADDRESS: v u ,, OWNER NAME: CORPORATION NAME (IF APPLICABLE)��. o,,>�,p,�g �pa � t � MANAGER'S NAME:��rt 1,.5 L�A�-l- !%u.�-I ca-1 TEL #CoR-l"1 I- Ola3 'L MAILING ADDRESS: �' • 6 - 3 �9- S 3'1 .E.�L. a,N),a�s u� OZC� �{� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list tl�e designated Pool Operator(s) and attach a copy of the certificatiou to this forni. I. Z_ Pool operators must list a inuiimum of two employees cun�eutly certified 'ui basic water safety, standard First Aid a�id Commuuity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to tlus forni. The Health Department ��ill not use past ��ears' records. You must provide ne�� copies and maintain a �le at your place of business. 1. 2. � 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establisiuneuts are requu-ed to have at least one fiill-time employee who is certified as a Food Protection Ma�ia�er, as defined in the State Sa�utaiy Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certificatiou to this applicatiou. The Health Department�vill not use past years' records. You must provide new copies and maintain a Gle at ��our establishment. i. /'C�—�-cc�J7t�%��4w 2. rz_SL� le�. � ��,d PERSON IN CHARGE: ?. .��e.l � W �, ca Eacf� food estaUlislunent must have at least one Yerson ln Charge (PIC) ou site duruie hours of'operatlou. 1.��„cc_c� S-�cr��buvy 2. ,/�� ,c.�w HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee trained in the He'vnlich Maneuver on the premises at all tnnes. Please list your em�loyees h�anied in anti-chokuig procedures below azid attach copies of employee certifications to this fonn. The Health Department will not use past��ears' records. You must provide new copies and maintain a 61e at ��our place of business. 1. e��LCt� ��j� 2. Lvv1'�t-v�t,� ��ti� l-�,l/ 3. e p 4. Lr- _- t-�c7-, v,��., c .i � � ...� vf r �� /ZO �j ^ RESTAURAN�SEATING: TOTAL # (8S "" ��4� 7 � '7. / �t rn c�.-c�k �G.�c cv - �- �+�'7°.�t ��4at7J.,,. OFFICE USE ONLY LODG[\G: LICENSE REQUIRED FEE PERi�IIT f� LICENSE REQUIRED FEE PER\41i= LICENSE REQL'IRED FEE PER\�IIT fi B�B S» _CABIN S55 _\IOTEL S�5 _ti.iv S55 _CA:\4P S» _5\t'D�INGPOOL S80ea. LODGE S» __TRAILERPARK 510� __ _\l�"HIRLPOOL SROea. FOOD SER\'ICE: LICENSE REQi,'IRED FEE PER\4I7= LICENSE REQtiIRED FEE PER\iff= LICL-NSE REQliIRED FEE PER\IIT= _0-100 SEAI'S S85 _CONTINENTAL S35 NOIQ-PROFII S30 I >IOOSEATS 5160 �f1-132 I CO\�IMONVIC. 560 ��_—�� _R'HOLESALE S80 RE'I�1IL SER�'ICE: —RESID.KIiCHE�' S30 LICENSEREQUIRED FEE PER�III'# LICENSEREQUIRED FEE PER�IlI� LICENSEREQIJIRED FEE PERbIIIx _vOsgB. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD S25 _<_S,OOOsq.Ti. S30 _FROZENDESSERT S40 70BACC0 S55 �a�[Ecx�acE: su ANTOUNTDUE _ $ 220,00 *"*""pLE,1SE'ItiR\OFER ASD CO�IPLETE OI'HER S1DE OF FOR�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 pernvt 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 SIGNF,D AND ATTACHED '`% Town of Yarmouth taYes and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES_� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes 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 ofresidence 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 which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection three(3)days pnor to opening. PLEASE NOTE: People aze NOT allowed to srt 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. YCJOL Li.1S511VG: 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 ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspect�on three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth 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 obtained at the Health Department, or from the Towd s website at www.yarmouth.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 Permit until the above terms have been met. OUTSIDE CAFES: OuYside cafe� (i.e-,ouTdo�r seating with waiter,h��aitresa service), must have prior appro��aa fr�m the R�ard nfHe,alth. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILTTY TO RETURN TFIE COMPLETED RENEWAL APPLICATION(S) AND REQiJIRED FEE(S) BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND;� ROVED BY THE BOARD UF HEALTH PRIOR TO COMMENCEMENTr: RENOVATIONS MAY R - E A SITE PLAN. DATL: % Z`' � % � �' SIGNATURE: �� PRINT NAME&TITLE: � �� 10'OE10 _ , � � The Commonwealth ofMassachusetLs Department ojlndustrin/AcciJents NAfaN� 600 Washington Street, f"Flaar Boston,Mass. 011ll Workers'CompensaHoo f�uorence Aftidavi,h Boildio�/Plambiny,/Ekctriey�ConMctors . - � P namc' e �Niv vt' �C-� 1 1 ,Tt�—' ��s ��a- G -- G sa-- ,d��--- �. g �{ ---- q---------�j --- ✓ - - ---- c� IU nMr,i ��}� state._ ._ � . zio:��(-� oho�re# ��`71 � ��/7 work site localion lfull addressl� � LJ [arn a homeowrer perf'omung all work myself. Pro ect T ❑ I � a sole proprietor and have no one wodcin �n an ca c� � Y�" �New Constnx;tion ORemodel g Y Pa lY� ❑Bwiding Addition I arn an empioyer providing workcrs'compensation for�employees working on t6is job. �mo,....m�• ��'1 t- �A � � �.Yk !� �J ad�as: "\ J d` �` 1 i; ? -% : •- ci % d �` �w: S�g �i v '"`�J '7� to.�..a�a C�� x f� � � _ ❑ I am a sole proprietor,gmenl co�tractor,or homeowaer(drele oneJ and have hired the contractn�s��ste�rye�aw who�6a�e the following woticers'compensation polices: e- ddroa: city: nhoee N iaamste to. M ��iL�s' ad�'et: eity: _ oio�e N imvaacero, _ . -.. - .. ._. . . _._ _ .. ,�sa.+�r.r+rr.......� e - F�B�re b xcns n reqdred��de SeNb�13A�f MCL 152 eu 4ad b IYe h�p�iW�dvioVd � . �Yen' riw P�MIe d�me R b f13M-M uN�r �'��P��ti��o!a 3TOl WORK ORDER�tl��ee d7100.0�a d�y�a1w�se, �oed�y�� tipy N Uh Ma y f�rw�rdcd oe tse ORke otI ` �n ef tse DIA far c�vera�e verlOnMw /Aa hertby ce�fy wn r lws awd penafNu oJperJrry thot rhe iwfonworion provJded abave&trre m�d rornrt r ._ Sigmtme '��.'� ) . Dah _ � L ��(,� � �7 Print natne � � � PhoM# �� . . . � � � �c�� o�Beia�uae only do na write I�[hh�ru fo he rnaplelcd�Y�Y wo o9kW . . . . . . .. Nty or tawp: p�rmiNlc�eme k ��y�� 61kpWmeot ❑checic Himmedi6e'e�peme b reqdred �IJceedae Be�rd ❑Seke�esl(118ce ��•��' phose M• OHuMi D�arO�a1 � � �(ltse