HomeMy WebLinkAboutApplication and WC .. G3�C���D
, TOWN OF YARMOUTH BOARD OF HEALTH "" `
APPLICAITON FOR LICENSE/P�I'�'�=201Qr���1 � NOV 1 9 TfJQJ
"` Please co lete form and attach all neces k� M b�t UtP�i�.
Fail�to do so will result in the retuni a�oc u�r a��li�n eac
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NAMEOFESTABLISHM�F��'��`-��S /�Y-v�=-/1 �uvr�:L TEL. # ���_ y�� �
LOCATION ADDRESS: r��/ ,e 7 1 Y_ ,�,,,r „7, _c 4� S�t� Tl-t Y%�2ttr�tl�,r�,�¢_a�C6�
MAILING ADDRESS:_ �i� .� ,. ,z � na.,1, ci-. sov�t-C �n,2��o v�;v . n-fA- _ L�G/-�
OWNER NAME: Nt f+��/D,� Q /S�-r-r TAX ID (FEIN or.�SN�
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: �o Ff � � �Ly_� (-�i�7'7' TEL. # S d��?6 9'`�� �3
MAILING ADDRESS: 5�y i /17_ �lr . ��. ,t, S-F sn c� ;rf �y u,,..R„v.� . .C�r�- d{G�
POOL CERTIFICATIONS: ��v �- �S C�US'�- � 7-��— Z � n �i - '
The pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificarion to this�f rm.
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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 $ file at yonr place of business.
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FOOD PROTECTION MANAGERS - 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 of certificarion to this application. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
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PERSON IN CHAitGE:
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Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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HEIMLICH CERTIFICATIONS:
All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your enployees trained in anri-chokmg procedures below and
attach copies of employee certificarions to this form. The Health Departroent will not use past years' records.
Yoa must provide new copies and maintaiu a file at your place of business.
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3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LIC$NSE REQUIRED FEE PERMIT# L[CENSE REQt1IItED FEE PERMIT# LICENSE REQU[RED FEE PERMIT#
_a,�s $ss _cAsav $ss I MOTEL $ss �l0—�16
._,_LNN $SS _CAA�+ %55 15R'IMI.4A'G POOL 580ee. �/0'���
_LODGE $55 �TRAII.,ERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQU(R£D FEE PERMIT# LICENSE REQiJIRED FEE PERMIT#
_0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT S30
>]00 SEATS $160 _COMMON VIC. $60 _WHOLESAL£ S80
RETAIL SERVICE: —RESID.KITCHEN S80
LICENSE REQUIILED FE6 PERMIT# LICENSE REQUIltED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT#i
_<SOsq.R S50 _>25,OOOsq.ft. $225 _VENllING-FOOD $25
,<25,OOOsq.ft. $80 _FROZENDESSERT $40 TOBACCO S55
xpME cBnxsE: sts AMOUNT DUE = S 135.o0
""""PLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM**"**
ADMINISTRATION
Uncter Chapter 152, Section ZSC, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernrit 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 INSUI2ANCE
AFFIDAVTT 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 permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Mote1 or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarilq 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 defitted in M.G.L. c. 64G or 830 CMR 64G, as unended, shall generally be considered Transieirt.
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be' p
by the Health Department prior to opening. Contact the Health Departmem to schedute the inspection three(��3)d�ay�s
pnor to opening. PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has been inspected
and opened.
POOL WATER TES1'ING: The water must be tested for pseudomonas,total coliform and standard plate courn
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
CATERING POLICY:
Anyone who caters witlun the Town of Yarmouth must notify the Yarmouth Health Departmeat by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These fortns 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 sent 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:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromtheBoard ofHealth
OUTDOOR COOKING:
Outdoor cooking�pre4aratioq 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 RESPONSIBILITY TO RETURN
T'HE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: SIGNATURE:
PRINT NAME&TITLE:
09/25/09
�\ The Commonwealth of Massachusetts
Depaetment ojlndustrial Accidents
MNSaN�
600 Washington Street, �"Flaor
Boston,Mass. 02111
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