HomeMy WebLinkAboutApplication and WC , " 1�3. 12. LIQuoP_S
' TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMPf�`2A10� 4� V�
* Please complete form and attach all necessary documents by Detember 1 S 2009.
Failure to do so wiIl result in the return of your applicatton pa'cTce�
NAME OF ESTABLISHMENT: PJ/�55 �1 i V C 2 L i ei2 wm�.s TEL. #50 8-�bu -SY`�q,
LOCATIONADDRESS: R31 Zi o�-F� 2L3 So�.�-l-I-� yi�2mou+l-!
MAILING ADDRE�S: Sa M�s
OWNER NAME: ��'� *� n � , I-ra k z o FE or S •
CORPORATION N (IF APPLICABLE):B,� s s iZ �vErZ D>'s cu k tik L:at worLs T'�,.,e -
MANAGER'S NAME: S.a .r� � TEL. #
MAILING ADDRESS: `�
POOL CERTIFICATIONS:
T6e pool supervisor must be certified as a Pool Operator,as required by State law. Ptease list the designated
Pool Operator(s) and attach a copy of the certificarion to this form.
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]ist these employees below and attach copies of empioyee
certificarions 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 1viANAGERS - 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 ofcertificarion to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your estabGshment.
I. 2.
PERSON IN CHARGE:
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 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees h'aiued in anti-chok�ng procedures below and
attach copies of employee certificarions to tlris form. T6e Health Department wilI not use past years' records.
You must provide new copies aud maintain a Cile at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQLJIRED FEE PERM[T# LICENSE REQUIRED FEE PERMI'1'# LICENSB REQU(RED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
�INN $55 _CAMP $55 �,SWIMMINGPOOL SSOex.
LODGE $55 TRAILERPARK $105 WI�IIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQUQ2ED FEE PERMIT# LICENSE REQtIIRED F£E PERMIT# LICENSE REQTlIRED FEE PERMIT it
0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
�>]00 SEATS $160 _COMMON VIC. $60 �WHOLESALE �80
RETAII,SERVICE: —RESID.KITCHEN S80
LICENSE REQiJIItED FFE PERMIT# LICENSE REQUIItEb FEE PERMI'f# LICENSE REQIIIRED FEE PERMI I#
��SOsq.B. $50 � O�0 >25,OOOsq.ft. $225 _VENDING-FOOD $25
_QS,OOOsq.ft. � $80 � � � � _FROZENDESSER? $40 � �TOBACCO S55 �(a-na3
x.a,ME cxnxGE: sis AMOUNT DUE _ $ I o5 •o0
•••'"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""**
.�., :
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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 A1"I'ACHED STATE WORKER'S COMPENSATION INSURANCE ,
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CI�CK
APPROPRIATELY IF PAID:
YES X NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transieirt occupaucy shall be
limited to the temporary and short term occupancy, ordinarily and customarily associaYed with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maurtain a principal place ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirry (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 shail not be considered tsansient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defitted 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 insDected
by the Health Department prior to opening. Contact the Health Departmem to schedule the inspection thr�(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,totat colifoim 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�round swirruning 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 Heaith Department by Sling the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be seat to the Health
Department. Failure to do so will resuit in the suspensiott or revocation of your Frozen Dessert Permit u�il 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 setvice astablishmern is prohibited.
_ . _
NOTICE:Permits run annually from January 1 to December 31. 1T IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIIdTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A SITE PLAN.
DATE: l z - - D �j SIGNATURE�,� l �
PRINT NAME&TITLE:l�.�� o a n �, l,p e,e.z o n� �iz�
09/25/09
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