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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF H��L�I `;�'� t �_", ' GC�O�'1(�DD � k� � APPLICATION FOR LICENSE/PERb�tI�'='2912' ' �p C,��`j�g� NOV 1 � 2011 * Please complete Form and attach a11 necessary documents by Decem6er 2011. Failure to do so will result in t he return o f your app licarion pac et. LTH D EPT. ESTABLISHMENT NAME: �UC�' � �D� " LOCATION ADDRESS: �"� M OZlo L.#: • `7 1 - $� MAII.ING ADDRESS: OWNER NAME: `� V�l �L CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: C TEL.#:J'rU - • ?L�� MAILING ADDRESS: �f i 0�(o POOL CERTIFICATIONS: The pool supervisor must be certifie as a Pool Operator,as required by State law. Please list the designated Pool Operator(s} and attach a copy of the certificatien to this for_m, - - -- -- 1. 2. Pool operators must list a minunum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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 Cle at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: !v�/T All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certif'ication to this application. The Health Department will not use past years'records. You must provide new copies and maintain a f'�le at your establishment l. 2. PERSON IN CHARC'iE: _ _ _ _ _ _ ___ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operadon. 1. 2. HEIMLICH CERTIFICATIONS: /J�/T All food service establishments with 25 s ts or more must have at least one employee trained in the Heunlich 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. You must provide new copies and maintain a�le at your place of business. 1. 2. 3. 4. RESTALTRANT SEATING: TOTAL#, OF'FICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 � _CABIN $55 _MOTEL $55 _IIJN $55 _CAMP $5� _SWIMMINGPOOL $80ea _LODGE $55 _TRAII,ER PARK $t05 _WfIIRI.POOL $SOea FOOD SERVICE: LICENSE REQUIRED FEE PERMTf# LICENSE REQUII2ED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _0-100 SEATS $85 _CONTTNENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# �<50 sq.ft. $50 1 a'��( _>25,000 sq.fr. $225 _VENDING-FOOD $25 _Q5,000 sq.fr. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAME CHANGE: $15 AMOLJNT DUE _ $ S7�• 0 0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORMk*x** � ; ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or permit to operate a business iF a person or company dces 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. AFFIDAVTI' SIGNED AND ATTACHED � Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGI�iG ES'1'ABLYSFIMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be lnnited 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 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 uansient. 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 pnor to opening.PLEASE NOTE:People are NOT allowed to sit in the pool uea 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 OPENIlVG: All food service establishments must be inspected by the Health Deparunent 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 Yarmouth must notify the Yannouth 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. F�"J�.EN DESSEIFTS: 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: �etsi�e e�es{::�;flt,��se:seating wit�hiva�erhi=aiLress servic�)>�u�i have-Yrn�ugl�ro r►,P u�ar��f Hzalth- OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUII2ED FEE(S)BY DECEMBER 15, 2011. 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 REQUIRE A S�PLA�� DATE: I �„I1 I I I SIGNATURE: PRINT NAME&TITLE:/�IUC�/ L I!�(I�� D GU N� Rev.10/25/11 r . �`"� The Commonwealth ofMassachusetts Department of Indusrrial AcciJenu M�eldi�GNs 600 Washingtoe Street, �"Floor Boston,Mass. 02111 Worlcers'Compeasatioa lusonace Aftidavk:� � . . . . . - . A�I�hr�tln• Plear PRINT kdbM � :, . name: address: cirv state: zio: ohone# � work sih locatian(full add�essl: - . ❑ I am a homeowner performing all wo�k myself. ❑ I am a sole proprietor ard have no one wocking in az�y cap�ity. � �I am an employer prm�iding wotkecs'compensation fa my employees wodcing on this job. J� ��1C�� '��.�. . .. . : -� .. . .. . eonoav rme: -- ��,: J�,�'I 21J U� o� D �..: _- l�J�sr vA�rJu� , M.k o��M: .sa8-�t�t - � �t 88 �,.a�. d(��nli�� STA�r� -QiU- c+�fl �T�S �.� v�coaa35oa�� ❑ I arn a sole praprietor,ge�eral coetractor,or homeewuer(ctrclt nwe)aed have hired t6e contractas lis[ad 6elow who�have the folbwing wwkers compenvation polices: . snmouv�aue• . ad�aa• eitv oiaee N: (esmKe eo. odkv N e000ur�ae• ad�rao• etlr Ma�elF. _ .. _ . . ._ -- ---- ---— - — - -----. -_ _-- -------__ Ine��eeea. .. _ odtevM �.++rrrwerr.....i F.rae r aeene e..e.,c n Rqrree■.av seew zsw.tMCL tu n.r,a b ne I�p.ilw.taf�rd pe.we.t.�e�a s1,1M.M a.rbr ne ynn'lepriwneeet n wd a dH penitln h Ise hr�ata S7'O�WORK ORDLR atl�me Mf1M.N a day aplmt se. 1 oderMW Wt• capy af ti6 YahoeM e�9 6e fi'warded e�tAe O�e d Iwe�YMr d Ne DIA far t+�en`e wNeatlw. !de Aereby certlfy rnder ths oelw n/peeal(lea ojpe�jrry dF�Me Iwfanwallon pndle!aborc h bve awAceiraet Sieoatorc Darc __�1�� /�} PtiM name 1 v l�• V V ��/�-- P6one k ��1' �� ( 0 O �. � .�.m�w■:.wy ao eet.rtkc d/e�.�,r.,co ee cooWelM hr dtr or e...n.mew � � . eNy or tawn: . . . . . . . permitlB�eme M OBoYdhn Deparfweat ❑cheek NimaedVt requme b d�M ❑��E Bsard Rq �.4ekcmet3 OfBte ❑IIeMY DRa�t roWa¢tpeiaon: P�reY� �Q . . t�a sm�mmr