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Home My WebLink AboutApplication and WC . S�`x�f'�aD �RMS � � TOWN OF YARMOUTH BOARD OF HEALTH � - APPLICATION FOR LICENSE/PERMIT�O ' ' �` �-' JAN�6 2011 * Please complete form and attach all necessary docu,n�ie�ts?1��e er IS 10. � Failure to do so will result in the return of,your appiication p,c ei '_.- �� ESTABLISHMENT NAME: ��A f"uaD 5�.�'1` TAX ID: � ¢- LOCATION ADDRESS: a Z TEL.#: � ,� 3�¢ MAILING ADDRESS: U v�/{ G1 FhL,r�e,i7/-� OWNER NAME: fF i/L oL v,v�7z o CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �{ �1vL L4�/�w��e2 TEL.#: � —,�j'4��¢ MAILING ADDRESS: ;_j'/I H � 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 certification to this form. 1. 2. Pool operators must list m' o ployees currently certified in basic water safety, standard First Aid and Community Cardiopulm Res s at on(CPR). Please list these employees below and attach copies ofemployee certifications to this fo . T e H a epartment will not use past years' records. You must provide new copies and maintain a �l t yo r lace of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protecrion 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. � i. �ff�//1 i ��L� �v2/!�I z. ��if� /�•9S�6N PERSON IN CHARGE: Each fooci establishment must hace af leasf one Person tn Charge (PIC) oii site durine hours of operation. L 2. HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee h•ained in the Heunlich Maneuver on the premises at all times. Please list yow• employees trained in anti-choking procedures below and attach copies of employee certifications to this foim. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. � �lair—�✓ ��2h 2. C' �� /�'I�r�N 3. ��A/i�L LL-�.✓ 4. �� lrv ,�"I� e/1 L= RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGL\G: LICENSE REQUIRED FEE PER'�III'# LICENSE REQU62ED FEE PER�fI7* LICENSE REQUIItED FEE PER'�III= B&B 555 CABIN S55 \40TEL S55 RVN 555 CAMP S» SFL'LbLVIING POOL SROea. LODGE 555 IRAII.ERPARK S105 \LZ-IIRLPOOL S80ea. FOOD SERVICE: LTCENSE REQUIRED FEE PER'bllI"= LICENSE REQUIRED FEE PER\�IIT�r LICENSE REQUIRED FEE PERMIT= I 0-100 SEATS S85 �(f—� .� _CONI'INENiAL S35 _NON-PROFIT 530 - _>I00 SEATS 5160 I CO1�II�ION VIC S60 �p-��j—O�i� _��'HOLESALE S80 REI':11L SER\10E: —RESID.KI7CI-IEN S80 LICENSE REQUIRED FEE PER�IIT= LICENSE REQUIRED FEE PERbIIT� LICENSE REQUIRED FEE PER�IR- _<50 sq.8. S50 _>25,000 sq.ft. 5225 VENDING-FOOD S25 _<z5,p00 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S55 �a�tEc�scE: sts AMOUNTDUE _ $ /�S,C)(1 """**PLEASE TUR�O!'ER A\D CO�iPLE'IE OiHER SIDE OF FOR�1«**"* _ .-..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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNEb, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taaces and liens must be paid prior t enewal or issuance of your pennits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO M()'TELS AIVD OTHER I.O�GATG ESIABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe 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 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 haue 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 are 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 ground swirruning 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 Department to schedule the inspect�on three(3) days prior to opening. CATERING POLICY: Anyone who caters wiUvn 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 Town'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 revocahon of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waitedwaitress service),must have prior approval from the Boazd ofHealth. OU'I`DOOR COOHING: 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 31. IT IS YOUR RESPONSIBILITP TO RETCJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQIJIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT: RENOVATIONS MAY RE�RE A SITE PI,.AN. �� DATE: � �4 /l SIGNATURE: C� �,r.��.----- PRINTNAME&TITLE: �f}UL �V�Lp��jZO (�G{//i/L-�"C_ io�oc io NOTICE � NOTICE TO TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachasetts 02111 617-727-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, ttris will give you notice that I(we)have provided for payment to our mjured employees under the above mentioned chapter by insuring with: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970 ADDRESS OF INSURANCE COMPAIVY WMZ 8003685012010 04/01/2010 - 04/01/2011 POLICY NUMBER EFFECTIVE DATES Rogers&Gray insurance Agency 20 Independence Drive Inc Hyannis MA 02601-1999 (508)775-0011 NAME OF INSURANCE AGENT ADDRFSS PAONE Seafood Sam's of S. Yarmouth Inc. dba Seafood Sam's 1056 Route 28 South Yarmouth, MA 02664 EMPLOYER ADDRESS 02/10/2010 EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDI AL TREATMENT 17�e above oamed iosurer is reqaired in cases of personal in,juries srising out of sud in the couise of employment to fumish adequate and reasoneble haspital and medical services in accordance wit6 the provisions of the Worlcers Compensatiou Act A copy of the Fvst RepoR of Injury mast be given to the iqjured employee. The employee may sdect hi4 or 6er owo physician. T6e reasonable cost ot the services provided by the h�eating physicien will be paid by the insurer,if the h�tment is necesazy and ressonably connected to tice work related iqjary. In cases requiring 6ospitsl attention,emPbyees are hereby n�ed thst the insurer has arranged for sac6 attention at t6e NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER