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Home My WebLink AboutApplication and WC c�,-d- �wa� ,: TOWN OF YARMOIITH BOARD OF HEALTH ��y o :" APPLICATION FOR LICENSE/PERMTi'-�!� "� i , �`..� �' � �B 0 5 2D'0 * Please complete form and attach all necessary documern . De� 009, Failure to do so will result in the return of your app�hon pac uEr i. NAME OF ESTA$LISHMENT:Y_��_ p/�N�.a .�� }q� TEL. #SU�',3C1 �-�j3 L LOCATION ADDRESS: a S� �p -r F Z g MAII,ING ADDRESS: " �� ' OWNER NAME: �(�bis1�+A-�� (�� ID (FEIN or SSN - CORPORATION NAME IF APPLICABLE : q�„r =+ k,�. � L-rj� MarraGEx°s rraME: : �SNA« R�� 4� TEL. #�b� -�� -�� 3- MAILING ADDRESS: d ,. POOL CERTIFICATIONS: The pool supervisor must be certi5ed as a Pool pperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minunum of two employees currently certified in basic water safety, standard First Aid and Commwrity Cazdiopulmonary Resuscitation(CPR). Please list these employees 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 file at yonr place of business. �. 2. 3. 4. FOOD PROTECTION�vIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protecrion Manager, as de&ned in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Aealth Department will not use past years'records. You must provide new copies and maintain a £de at your establishment. �. � ��- �� z. As�--�u �-�,-�A�� PERSON IN CHARGE: `J U�N dD�?�� Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. R�� O .tS"�3�-/�S� 2. 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 anri-chokmg procedures below and attach copies of employee certificarions to tlris fonn. The Health Department will not use past years' records. You must provide aew copies and maintain a file at your place of business. � 1. / nNI , �A d(r�_ 2. �T1lL% �G� S�1�L� 3. =i__t�8� ��i c/,a NL5 4. .�Q9.a„I�—,�qrP�,�G.s �_ RESTAURANT SEATING: TOTAL # I b'l� LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQLIIRED FEE PERMI7 # LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MO?EL $55 _]P7N $55 _CAMP $55 �SWIMMINGPOOL �.ROen. _LODGE $55 _TRAILERPARK $105 _W6IlRI,POOL $SOea. FOOD SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED F£E PERMIT# LICENSE REQIJIRED FEE PERMIT# _0-100 SEATS $85 _CONTTNENTqL S35 TNON-PROFIT S30 ,�>100 SEATS $160 �LQ�((�L � COMMON VIC. $60 � �Q _WHOLESAL£ $80 RET.AQ,SERVICE: —RESID.KITCHEN S80 LICENSE REQUIItED FEE PERMIT# LICENSE REQLIIRED FEE PERMI1'# LICENSE REQLJIRED FEE PERMIT# _<SOsq.ft. S50 _>25,OOOsq.ft. $225 _VENDING-FOOD S25 _QS,OOOsq.ft� � $80 � � � � _FROZENDESSERT $40 � TTOBACCO $55 x`��H�vGE: sls AMOUNTDUE _ $ 2zo. 00 """•PLEA5E TURN OVER AND COMPLETE OTHER SIDE OF FORM••*•• __ � � AD��VISTRATION ,; .. Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMFENSATION INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. 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 ,� NO MOTELS AND OTHER LODGING ESTABLIS�NTS T12ANSIENT OCCUPANCI': For purposes of the limitauons of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associaYed with motel and hotel use. Transient occupants must have and be able to demonstsate that they maimain 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 sha11 nat 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 genetally be considered Transieut. POOLS POOL OPENING:All swimming,wading and whirlpools which have been ctosed for the season must be insp�d by the Health Departmentprior to opening. Contact the Health Departmem to schedule the inspection three(3)days pnor to opening.�ASE NOTE:People are NOT allowed to sit m the pool area until the pool has baen inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total colifoim and standard plate coutrt by a State certified lab, and submitted to the Aealth Department three (3) days prior to opemng, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(�days of closing. FOOD SERViCE CATERING POLICY: Anyone who caters witlrin the Town of Yarmouth must notify the Yarmouth Heaith Departmeut by filing the require,�1 Temporary Food Service Application form 72 hours prior to the catered event. These fonns can be obtained at tt►e 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 Permit 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 ofHealth. OUTDOOR COOKING: Outdoor cooking,prepazatioq or display of any food product by a retail or food service establishmerrt is proW'bited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RE5PONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(5)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD EST LI , MO'I'F,L OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED � ROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS M Y RE UT A SITE PLAN. DATE: I 3l I b SIGNATURE: � PRINT NAME&TITLE: AQ�tk�k- �AR- � ! 09/25/09 �.� � ` The Commonwealth ojMassachusetts Department of Industria(Accidents �CE N� 600 Washington Street, 7`"Flaor Boston,Mass, 02111 Workers'Compeasation(aa�aaee Atfidav&:Baildiog/Plembiag/Ekctrical Cootractors � t , Heaae PR_TM7'k�i61v na�ne: / � L!N/�FLS'R�� address: Q �7 �h 17' 1� 2 �� J �,4ctr+ba� �re�� o�j�l6� �a saa 39g��.✓ work site location(fitll addiessY. �. . r . ❑ I am a homeowcer performing all work myself. Project Type: ❑New Conshuction QRemadel ❑ I azn a sole�propri�or aod have ao otie wodcing in any�capacity. ❑guilding Addition �I am an anployer providiog_walcecs'compeasatio�fa my employces wodcing�this job. comomv aame- . . � .. � . . . . � . addros' � . . . . . . . . �citr: � � . . . . . . � . . . M: / " R D 8—//�7�3 ❑ Iam a sole �� u �,,.>: � ,.,. ;� :. ., ..�_ :. . , ,,: . . �:.; �� . :,,- �3,:��, ,��.:: R`aPriefor,8da�a1 coatractor,or 4omeew.er(drde awe)md have hired tl�e contcactas listed below who have ihe following wodce.�'corppensahon pplic�; . . tOOO�OP�ipl: �� ' � . � . . . - iA�dT . � � . . � � . . . . . . . �C . , � . . �� . .. . . . . . . . . �i@i�Cl�9. . . � . . .. � � . : . .. ... . ... . ... ,. .. . �..: _ 2it t.,.F"nah3�pF:,",�3A�.-: ��tle!• � . . ... �' ��. . � . . . . . . � . . �� - .. . . � . . . � . _. �{ � _ _ _ . . . n ��.t �..�,� ��.< Eatver�eenear.Q,6ea�tsv�rNoavseetl..uA.tu�cLtua.kaac.irei�p'wt�w.rarr.r� �. �..��'��-�'�'"-:' �. �7�+'dprdwwtnwUudHpnWbdt0e6teKa370lWORCORDBRud�meHS1M.N�a ��faLeRb=13M.Ma�d/r �°F7��m�6etacwrdeAbMeOmadlapp��fdeDlAtrpwagevea�nryea - �7R��e. lod�Mldta I!e Aanwy coer6fy,u�rer qYe patns.ndv�neu(«ojp�ajay ua dYt infasnmton pna/el.eorc h sve iw/cs.rtcc� . . . . �� . . . Date PriM name . .. . . . � P6one#� . .. �dalaeNly Aurtw'keYtWunM6tey�Medb9dly�rbw��rL1 . . . . � . dy x bwr: P�i n�� c�iCbse�6!�e h tqr`ed .. . . �� . � . � .. �B�ara �L O�a (�pvw: . �� ! �