The URL can be used to link to this page

Home My WebLink AboutApplication and WC + � TOWN OF XARMOUTH BOARD OF HEAI�H � �� ,� �� ; °�D �� APPLICATION FOR LICENSE/PERM�1''� !1} ��r ..,. .J �,.\�� L�";�. * Please complete form and attach all necessary documentS'by ece er I S 2I�10. Failure to do so will result in the return of your applicat�on pa ketk{EqLTH D�PT,:. ESTABLISHMENT NAME: '� UG!-I 'F � Cl�� TAX ID: LOCATION ADDRESS: '1J21 RO?J� Z�6. 1,U U AA/TU-�'� �1/a /�'7,(0`?� TEL.#: �jOS� 7'�/-(o4�ig MAILING ADDRESS:�I�L� OWNER NAME: �QfVc`] W�� CORPORATION NAME (IF APPLICABLE): Pl iE MANAGER'SNAME: C CUl TEL.#: MAILING ADDRESS: j�juJN '( POOL CERTIFICATIONS: nI A" The pool supervisor must be cer ified as a Pool Operator,as required by State law. Please list the desienated Pool Operator(s) and attach a copy of the cenification to this forni. 1. 2. Pool operators must list a minimum of two employees cun•ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this forcn. The Health Department will not use past y�ears' records. You must provide new copies and maintain a file at your place of business. I. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: N�>� All food sercice establishments az-e requu-ed to have at least one ill-time employee who is certified as a Food Protection Manaeer, as defined 'ui the State Sanitary Code for Food Seivice Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wil►not use past years' records. You must provide new wpies and maintain a file at y�our establishment. 1. Z. PERSON IN CHARGE: _ __ __ _ _ - __ Each food establislunent must have at least one Person In Charge (PIC)on site durine hours of operation. I. 2. HEIMLICH CERTIFICATIONS: �� All food service establishments with 25 eats or more must have at least one employee mained in the Heimlich Maneuver on the premises at ali times. Please list your 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 ptace of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # Lonc��c: OFFICE USE ONLY LICENSE REQUIRED FEE PERVIII'?? LICENSE REQUIRED FEE PER�41i� LICENSE REQNRED FEE PER'�III'_ _B&B S55 CABIN S55 MOTEL S55 _!I��' S5� CA'+1? S55 S�t'ISi:.iSIvG POCi SSOea. _LODGE S55 _I'RAII.ERPARK SI05 ��y'I-IIRLPOOL SSOea. FOOD 5ERVICE: LICENSE REQUIRED FEE PERMI'I= LICENSE REQUIRED FEE PER\4IT# LICENSE REQUIRED FEE PER�I[T# _0-]00 SEAIS S85 _CONIINENI'AL S35 NON-PROFII' S30 _>I00 SEATS SI60 _CONLMON VIC S60 �lZ-IOLESALE S80 RETAIL SERVICE: —RESID.KI'ICHEN S80 LICENSE REQUIRED FEE PER'�IIT� LICENSE REQUIRED FEE PER\-SIi� LICENSE REQUIRED FEE �PERtiIII tt I <SOsq.ft. S50 I�OIp _>25,OOOsq.$. 5225 VENDING-FOOD S?> _<zj,000sq.ft. S30 _FROZENDESSERT S40 'IOBACCO S55 �A�iE CHA:\GE: S15 AMOUNT DUE _ $ SO.op "`****pLEASE'ItiR\O�'ER A\D CO�IPLE'IE OTHER SIDE OF FOR�i'"""* ADMINISTRATION � 1 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 AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓ Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO _ MOTELS AND �THER LODGING ESTA�LISIl�MENTS TRANSIENT OCCUPANCI': For purposes of the 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 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 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 swimttring,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. PI.EASE NOTE: People aze NOT allowed to sit m the pool azea 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 OPENING: All food service establishments must be i�s�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspectaon 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 Town's website at www.yarmouth.ma.us under Health Department,Downloadable Forms. FR�ZETi 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 Pemrit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seatingwith wait_er/waitress service),must have prior_approval from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTTCE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETCJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIlZED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, 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 REQUIRE A SITE PLAN. DATE: � I �O SIGNATURE: �CUG�/� PRINT NAME&TITLE: I I.I�IJ �,1� io-oc��o • � The Commonwealth ofMassachusetts Deparhneat ojlndastria(Accidexts M/felNf� 600 Washington Sdeet, �"Floor Boston,Mass, 02111 Workers'CompensaHoo iroennee Atfldavin go��d�oglpbmbiny/Ekctricyl Contraeton' � � � �TMTkpibl. � narce: address: Cfri siate� —_. __ Z1D D II WnfIC SIfC IOCB(100(f1III 3ddle$S)' . �J I aru a homeowcer perfocmmg all work myself. Pro�ect Type: �New Constrix:.tion�Remodel ❑ I am a sole proprietor and have no one working in any capacity. �gw��g p��on [v7 I am an�nployer providing worke�s'compensation for my employees working on this job. �m�...�: '(�oc�E� n� �QE Co7 , .��.: �2'1 �o U� ZR �: Iti��vA�n��rv�6T�lp� aZ(��3��M 50$ '7� I �Y88 ,o,�% GKAN ��i� s1'�-A►�tC�ya(�hs �.a WGpp2 5OZ((v ❑ I am a sole proprietor.gmeral co�tractor.or homeowner(circ%one)and have hirod the contracto�s lis[ed below who�have the following workers'cumpensation polices: comour me• ■d�ar c(tv oYose R . fesmaete ce. � ad�eu• �" n�o�s N ie' eo,_ . . _ _ .. _ . . . ._ _ __ . .. .____. —_. _ __ �______ . . - ------� --- ---. ._._ .ura.+rrrrr.er.....� K F�Yue b areoe ovvade n rtqdrM�idv Sec1M 1SA ef MCL 15!eu Ind b 1Ye IspniW��fobYid . . . � . °�e Ydn'Isprleoaerat a wN n dH pwMln la lee t�e(a SfOI WORK ORDBR u0�eee dll W.O��t�eae�a Sl�llM aW�r �epy Nfi6 af+ie�nl n�y Ae fennrdM es Me ORlee ati�veNldW�o af He DIA far e�ve�e veAenW�. Y��me. I mdmWd tWt■ !Io hereby cntlfy rnder Me palwaprtd penaMv ojperjury f rt NYe lwforw�r�fon provJded abarr&l�ue d irtc[ Sigrem'e��/�/ t� IT �,�� h �t� '� l i �D PM�� NAN�y � n � t.l��K PhaM» .�iDF ��? ( -(0 4$ olbei�l ux oaly do na wrke d Ihh aro b be comP��Y�'w 1�wa oCkhl . . � � . � eNy ar tawe: PermiMkeme N ❑cheek KimmtM�!reapeme i�rtqdred � ❑��k��oE BwN e QSHet�ta'�qBe< melaet penoa: �M �Ndkh Dmardewl In.�re S.p mml � ��Q . .