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Home My WebLink AboutApplication and WC a. _ A To�cH oF C.C. � TOWN OF YARMOUTH BOARD OF HEALTH- � -. APPLICATION FOR LICENSE/PERNIIT-2010 ` ��d�D ' �� > * Please complete form and attach all necessary document,c�b3%Dec 908�109 Faiture to do so will result in the retum of yo�sr'application p �EAL I H GtY 1 . NAME OF ESTA$LISHMENT: D� � CDCI- TEL. #Jr'D�'7'I 1 -��I$�( LOCATION ADDRESS: .�1 22� '� MAILINGADDRESS: ME OWNER NAME: D E or S N • ? CORPORATION NAME (IF APPLICABLE): /� i� MANAGER'SNAME: i� NC )L(3U TEL. # • Z -7�bS MAILINGADDRESS:$(o� AI�YV7DWn! KD i (..�f1�1� IL[S Mh O�� POOL CERTIFICATIONS: �� The pool supervisor must be ce fied as a Pool Operator,as required by State law. Please list the designated ---PQol�er�toz(s)_a�aitac�a_c�DV O£��estific��o�t9_t_Iv�fQrm_-----.- 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary 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 file at your place of business. 1. 2. 3. 4. FOOD PROTECTION�v1ANAGERS - CERTIFICATIONS: N�� 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 tlris application. The Aealth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN�HARGE; Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: ��/"� All food service establishments with 25 s ats or more must have at least one employee uained in the Heimlich Maneuver on the premises at all times. Please list your enployees uained in anri-cbokutg procedures below and attach copies of employee ceiYificarions to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# LICENSE REQUIRED FEE PERM[T# _B&B $55 _CABIN $55 _MOTEL $55 INN $55 _CAMP $55 _SWIbINIlNGPOOL SROee. LODGE $55 TRAII,ERPARK $105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED F£E PERMIT# LICENSE REQUIRED FEE PERMIT# b100 SEATS $85 _CON1'INENTAL $35 NON-PROFI? S30 >100 SEATS $160 _COMMON VIC. $60 ,WHOLESALE $80 RETAII.SERVICE: —RESID.KiTCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# LIC£NSE REQUIRED FEE PERM(T# 1 <SOsq.ft. S50 $(O�O�p >25,OOOsq.ft. 8225 _VENDING-FOOD 825 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO S55 NaMEcaaxGE: st5 AMOUNTDUE _ $ 50-00 '•"""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•*«" , ADMINISTRATION Under Chapter 152, Seccion 25C, Subsecrion 6,the Town of Yattnouth is now required to hold issuance or renewal of anylicense or pemrit to operate a business if a person or company does not have a Certificate of Worker's Compensatiom Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT. OF INSURANCE ATTACHED OR / WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED �� Town of Yarrnouth taxes and liens must be paid prior to renewal or issuance of yow pernuts. PLEASE CI�CK APPROPRIATELY IF PAID: YES �/ NO MOTELS AND OTHER LODGING ESTABLISHIV�NTS T12ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hatel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarilq and customarily associaYed with motel and hotel use. Transient occupants must have and be able to demonstrate that they maimain a principal place ofresidence elsewhere. Transient occupancy shall generally refer to corninuous 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. PC10LS _ _ POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Fiealth Department prior to opening. Contact the Health Departmem to schedule the inspection tl�rce(3)days pnor to opening. PLEASE NOTE:People aze NOT allowed to sit m the pool azea until the pool has baen inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified tab, 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 CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered evern. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthiy basis by a State certified lab. Test results must be sent to the Health DepaRment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pennit ucrtit 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 ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN TI�COMPLETED RENEWAL APFLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), M[JST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I I '�q _ SIGNATURE: � �U !�(/U PRINT NAME&TITLE: N • W t L�JU}Z (,t11JE�. 09/25!09 . . + v � The Commonwealth of Massachusetts Depa+tment of[nduslrial Accidents N�N� 600 Washiagton Stree� fa Floo� Boston,Mass. 011ll Worlcers'Compeosatioe Iavaraace�At[davk:Baildiog/Plambiag/Ekchical Coutnctors � Aoolieast[�fatmttlwt: Please Pl��1T k�rlt na�ne: address: � . citv � sfate' � zio�� phoneq � work site location(Cut1 addiessL : ❑ i am a homeowcer perfoiming all wox�c myself. Project Type: ❑New Constnwti�QRemodel ❑ I arn a sole{sopcie[or and�ve no one wadciog in arry�capacity. ❑Bwlding Addition [�I am an employer}xovidiog workas'compensati�for my�ployees wodciog�this job. - - �J��7,��$�(� ��1= �m�.�..�_ - --- --- --- — �: �;�,: (,�1�5'� �A f��-�'� ,�11F Ck2(v13 �r; �d'd'?71-(o48g �. � u� s�r � n►s co w��oos-aR-a9oo . .. . , . . _ . .�,.._ .�,...�. � , -,,.�rt�:� ❑ I am a sole propci�oy ge■eral eo�traetar,or homeewoer(mrde one)�d�luve hirod the con�actas lis�ed below who have� the following wodcecs'compensation pulices; . . 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