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Home My WebLink AboutApplication and WC .- -' i �,"'Af;u�� ?fiM�' ' � ^� TOWN OF YARMOUTH BOARD OF HEALTH � _ APPLICATION FOR LICENSE✓P T 2014'` „�u 0 3 [013 * Please complete form and attach all necess; y ember 13 2013. Failure to do so will result in the ret�n y F" ` li�u . ESTABLISHMENT NAME: T71uCJ + J' TAX ID: LOCATION ADDRESS: / h v �v 72avr c� Z� TEL.#: ,j�J��-i¢-3.f�4 MAILING ADDRESS: /0 0 L �La�Tt= Z � E-MAIL ADDRESS:_ c�&�YY�v,p 7�9✓L� �aA rA�T .v�i OWNER NAME: _ T At1L NuL uwc-rr�J CORPORATION NAME (IF A�PLICABLE): ,(��'��v,t7 SrYh� J s� .I'av� r/J,9yt��vTh`�.�N� MANAGER'SNAME: AvL �aG,,,,r,� TEL.#: ��-34�� MAILINGADDRESS: e1/a �i,: Ll Zo.9,0 , �. SiUv04, iu� 1�1d�� 0,3-5`3? 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 c ification to this form. 1. 2. Pool operators must 1 st a min' um of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopu on esuscitation(CPR),having one certified employee on premises at all times. Please list the employees below ch copies of their certifications to this form. The Health Department will not use past years' records. You m t provide new copie and maintain a file at your place of business. 1. �� 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-tnne employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Deparhnent will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. � �� lti1/�o n/ 2. �a.0 fJ-Tf�n.V c�a�2 it� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. �`��6�"J D�✓ 2. '�ZlA/ /fi'�ri�J ��i'/�'i'L�_ ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. �I/�4'IDYLi£ l�l��/�' 2. �.t/ �d?C-� /�'t�'o/'� � HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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 Tile at your place of business. i. JaNyqTbh� �va2h 2. T�lI�S 1/i�loA,�, o�� 3. 4. RESTAi.JRANT SEATING: TOTAL# -- - _ _ -- --- _ ---t11�'FICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 OL DGE $55 TRAILERPARK $105 _WHIRLPOOL Oea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQIDRED FEE PERMIT# �0-100SEATS $85 �� — ��'7C CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $160 ( COMMON VIC. $60 . Jc�;:' _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ I`-G 7 ,GC **'•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****• � �. ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit 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 MLJST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED � OR WORI{ER'S COMP. 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 ESTABLISHMENTS ' _- —_ _ _ _ _ __ ' -- _ TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinazily 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 sha11 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 Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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. ', _ _ . _ _ _ F`OOD SERVIC`E __ _ __ 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 Yatmouth 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 Town's website at www.yarmouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DE5SERTS: Frozen desserts must be tested by a State certified lab priar to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation ofyour 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 from the Board of Health. OUTDOOR COOHING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. �_ -� NOTICE: Permits run annually from January ] to December 3 L IT IS YOUR RESPONSIBILITY TO RETURiv THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. 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 REQU]��TE PLACN.�< DATE:_�/��'��.3 SIGNAT[JRE: (� c PRINT NAME&TITLE: �/17/L �dG G.vNr'Lc� C3 Cv N�7�— Rev. 10/OS/13 CERTIFICATE OF LIABILITY INSURANCE °"'��i�3 � �ad�� THIS CERTIFICATE IS ISSUED AS A MATTER OF Rogers&Gray Insurance Agenc.y,I�. INFORMATION ONLY AND CONFERS NO RICYiTS UPON THE �,y R�� CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT �ry�p�,p�p �p AMEND,EXTEND OR ALTER THE COYERAGE AFFORDED BY - THE POLICIES BELOW. e MISURERS AFFORDING COVERAGE NAIC� � �"�� INSURER A MA Re�if�Rs WC G�oup I�. Seafaod Sams SouM�Yartnouth,i�. INSURER B: drt�la Se�ood Sam's ��Z8 INSURER C: � ��Y�'�� INSURER D: r ` INSURER E: COVERAGES trfe Pa.�aes oF msu�us�o eeww wive eeeN issueo ro n�nsu€o wu�o aeove raa n€roucr v�raoo inwcnteo.r�orwnurnndac �wr r�nwr�r+r�raa oa connmox�un carmacr ax on�e oocu�xr wm�srecr ro waai nss ce�acnre�ar�iss�o ort�anv PERTNNTHE INStMiANCE AF�ED BYhE POIJqES DESCRIBEDlIEREIN IS SUBJECTTO ALL7FIE 7Ef7M5,IXq.US10PS MA tX1/�ITONS OF SUCN POLJdES. M3GREGAIE IAfTS SHOWi M11Y W1VE BEEN REOUCEDBY PAIDCLAiLS. 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