Loading...
HomeMy WebLinkAboutApplication and WC ^` ��' ` _ . � ^' �� TOWN OF YARMOUTH BOARD OF6��'L,A�1`�i . � � � ���� ��� -�-�' APPLICATION FOR LICENSE/P��'I'-2011 � ' , �� Ain�s� � 1 ;, ��� � .. Y . . ilv)Y J )._iJ . ' * Please complete form and attach all necessary documents b ecem er I S 2010 Failure to do so will result in the return of yaur application pa et. DEPT. ESTABLISHMENT NAME: �,�}�x�����? L t�� TAX ID: _ LOCATION ADDRESS: �y� Q-T � � SoUrl-i Y�;e tit a �l� TEL # Sb �- 3 9 $--�'� �+"' MAILING ADDRESS: Sr� / Q� �X _ c �,Jt�I '�.( ru p �/7k-�: M/.� D �L�6� �1�I. OWNER NAME:�hA�.�f==N�� �� G�./-�-7�-7- CORPORATION NAME (IF APPLICABLE): - MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certiGed 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 forni_ L � T = -- cs o ,yt�'�"}�"`� Pool operators must list a minnnum of two emplo ees cun•ently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CP ). Please list these employees below and attach copies ofemployee certifications to this foim. The Health Department will not use past years' records. You must provide new copies and maintain a fi►e at your place of business. i. R �y s -r����Jsa x� 2._ 1��t tt c>vDP�- (��-r� 3. ' 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Q1/A. All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manaeer, as defined 'ui the State Sanitaiy Code for Food Seivice Establishments, 105 CMR 590.000. Please attach copies of certification to tlus application. The Heaith Department will not use past��ears'records. You must provide new copies and maintain a Cle at your estabiishment. 1. Z. PERSON IN CHARGE: Each food establislunent must have at Ieast one Person In Charge (PIC) on site during hours of o�eratiou. I. Z, HEIMLICH CERTIFICATIONS: jv R All food seivice establishments with 25 seats or more must have at least one employee a•ained in the Heimlicl� Maneuver on the premises at all times. Please list your employees tranied in anti-chokuie procedures below aud 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. Z. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER'�III� LICENSE REQUIRED FEE PER\4IT� LICENSE REQUIRED FEE PER�SIT- _sas sss _caBtN sss I �torEL sss I� —T�`� S�� _CA�ff S» I S�bT�fING POOL S80ea.�'I��p _LODGE S55 _IRAILERPARK 570� «'FiIRLPOOL 580ea. FOOD SER�ICE: LICENSE REQLnRED FEE PERbtlr= LICENSE REQUIRED FEE PER�4II'= LICENSE REQUIRED FEE PER�iff= _0-100 SEATS S85 _CONI�INENTAL S35 NON-PROFIT 530 _>I00 SEATS 5160 _CONLNION VIC. S60 �iI-IOLESALE S80 RE7.1IL SER�'ICE: —RESID.KITCHEN S30 LICENSE REQUIRED FEE PER�III'= LICENSE REQUIRED FEE PER\-SII'# LICENSE REQUIRED FEE PER�41T� _<SOsq.B. S50 _>25,OOOsq.ft. 5225 VENDINC,-FOOD S25 _Q5,000 sq.ft. S80 _FROZEN DESSERI' S40 TOBACCO S55 �:��7E c��cE: sis AMOUNT DUE _ � I 3 S.00 *'«""pLEASE TCR\OVERA\D CO�iPLE'IE OI'HER SIDE OF FOR�I""'"«* � , ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance oi 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 WOI2KER'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 taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO M()TEL3 AN� O'I'T�F'R ���GING ESTr�BT ISI�MENTS 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 wnsidered 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 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 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 ins�ected 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 within the Town of Yazmouth must notify the Yarmouth Health Departmem 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 revocat�on of your Frozen Dessert Pernut until the above terms have been met. OUTSIDE CAFES: na±�e�{�P.,�e�tdeor seating?uith waiier/waitresssererice�;mustbave prior approval from the BQazd ofHealth. OUTDOOR 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, 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 SITE PLAN. DATE: {p � ��.— � 0 SIGNATURE: yy�,ra/��^�"�`� �-- ���I�t/� PRINT NAME &TITLE: N E � k�47—� � 10�06'10 / ' `��� - : q r/o-�' O�e h � n � 1'0o I ���U�c�sE - '��•�, No c hev� i c � � s , v� 5 1� �c�l r�:$iso.00 � ' � TOWN OF YARMOUTH BOARD OF HEALTH � �' 201U12 HANDLING AND STORAGE OF TORIC OR HAZARDOUS �'E�5-�IF� � APPLICATION - - i_n„ PLEASE COMPLETE ALL U TT x �U�1 3 0 2011 /3A55 /� v naa��� NAME OF BUSINESS ��"'kµ�� � hu BUSINESS TII,. '�' '� � susIIVFss nvnxEss �t y I R-T. tg. n,� ,�� s-r_ svv-��i '��v7tF,�.�cQ�, uzcsj MAILING"ADDRESS �aMt� MANAGER/CONTACTPERSONA�EtGNpB-t1 �--8lf,�l� HOMETEL.#B'68�6�(le—G("7 7' OWNER NAME G�tEX��'?/-+4 Q�j(C'�LiE � N�-Cl HOME TEL.# ��<3��Y-- �t S49 HOME ADDRESS�/ ' /L1_ a�Nt�� S'r �JU�t-E vA�-i�dU`l� n.t.11_ 026+l� CORPORATIONNAME(IFAPPLICABLE)-U_C 7 ������� �i..# ,g'aSf-�69r�[:f�9 CORPORATIONADDRESS ��l l f�7� .Lf� ��3T- SOUI'L-�-- ��.c�U`I��� MAILING ADDRESS SrrK� TAX ID(FEIN OR SSN) ��- LICINSES RUN ANNUALLY FROM NLY 1 TO JUNE 30. IT IS YOUR RESPONSIBILITY TO RETURN'ff� COMPLECED APPLICATION(S)AND REQUIRED FEE(S)BY JIJNE 30. FAILURE TO DO SO WII.L RESULT IN CLOSURE OF YOUR ESTABLISHIvIIIVT UNTII.Tf�REQUIRED APPLICATIONS(S)AND FEE(S)ARE RECEIVED. A HEARING BEFORE TE�BOARD OF HEALTH MAY BE REQUIRED PRIOR TO REOPENING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your perroits. Please check appropriately if paid: yes� no_ n/a_ Under Chapter 152.Sec.25G,subaection 6,the Town of Yazmouth is required co hold issuaocc or re�wal of any license or pernrit to opeiste a business if a person or company does not have a Cetfification of Workers Compensation visurarice. As paR of renewal or issuance of your permits,you must complete We endosed Workers Compensation A[fidaviG If not applicable,please explain: REGISTRATION FORM SIGNED AND COMPLEI'ED ,� CHECK AND WORKERS COMP AFFIDAVIT INCLOSED _ � N Ai.i.MATERIAL SAFETY DATA SHEETS ON FILE Y N ANY NEW CHEMICALS MUST BE PRE-APPROVED BY TFIE HEALTH DEPARTMENT. RENEWAL APPLICATION'✓ NEW APPLICATION APPLICANT'S SIGNATURE h�Lcvr� R- _ .l�r�.w�C DATE 6" �G �I � i . � , �\ The Commonwealth of MassachusetLs Deparh�eertt of Industria(Accidents . �a� 600 Washington Sdeet, 7"�Floor Boston,Mass. 0211! Workers'Compensation Iroannce AftidavN: B.ildiug/Plambieg/Ekc[rical Contractoro �� � � � �11�t i�Pw�itla: Please I�►I'keibl� narne� /� �� �/vi�/�!'+ R, � �^'���Z � addnss: .--CLI—L— �_�•___'2' 0�—.--_—_�/-s��/`� ST_.—_ S� �D �f�7�r/ �l�� T,N smte� /�tT zip U' � r� �yohone# S�U j 9£� l��i S'8� work site lacation full addnss: . I am a homeowrer perfom�ing all work myself. Projec[Type: �New Cons4vction QRemodel ❑ I am a sole proprietor and have no one working in any capacity• ❑Bwlding Addition ❑ I arn an employer providing workecs'compensation Tor my employees workiug on thiy job. comw�vme: - . . .. . .. _ . _ _.. _; ;. .. _ . . _ . . . . ... - -- addres- citr: oYoee M lutmaioe eo. ��# ❑ 1 am a sole etor, eaeral codrsc[or,or homeowner(clrc%nn�)ar�d(�ave hired the c�nhactas lis[ed below w!q have P�� S t6e following workers'compensation polices: rnmouv eame• addraa: citv: o`�� inmaeee cu, k mmo..v uoe• . ad�ess• eitr: o�e�s k ... . inv��ccea . . ._. __ . . __-_. _ . . _ __.. _ _ _ __ . __. . ._. _ .__. _ . _. ____.. _. oolte.9 err�.+srrY,+.et r....rf F�iln^e d aeeve ee�ea{e n reqdrM�edQ Sae1M�33A d MCL 13I eu Ind b IYe . . . . °�e re+n•Ioarha..e.l,..�a..wr �4'�•ral.rd pe..Mo.r.m.e�r b ASN.M.w�.r peoaMb la tse Ar�eta 3TOl WORK ORDER arl�eee e(S19lN a dq apieN me. i�db�a �py Ntlh�laieaem my be f�rw�rded b tAt Oelee d laveatlptlw of tlie DIA hr avveraee verletatln. /do hereby cerdfy r�der NYe pelwa and pewaMe o JPerJrry+Aet Me fwjonwoNon prov7ded a6owr fs pye m�f rnrrrct SiB�uN�e_�ylAi�i...Q✓1 -Yl_[i l�`ni� � Dah /O — Z.Z" � O r�;,��� M� N fr�l(�/�� Q (S�fA•�—P enaMk �� �f — 3 �G �"�2 -'z`S� are�w�o0y a.ow w.«�s�m..n.�.n��vwN�a nr d�r o�wm oa�w eHy or eswu• . permiUtleeme C ❑Buidmt Dcpat�enl ❑check Ifimmedl�4 re�psme(�rtqdred DlJcesalus Bprd �-��'s OIB�e roafaet Penpc �M. QNnkY D�arh�eat (n.me sy�mm� � �10Q .