HomeMy WebLinkAboutApplication and WC • ��� TOWN OF YARMOUTH BOARD ORHEALTH _ .--`"�. AcAPUc.CoS ,
APPLICATION FOR LICENSE/PERIV�TT-2011 j
�� * Please complete form and attach all necessary do'Cuments'by De��b�r I S 201 Q ;
Failure to do so will result in the retum of ybuf application pack t
ESTABLISHMENTNAME: J'�CC�'�1.�1CC�`� ��t 1CCr �C� .'7�.;`l'�'4�AXID � ���
LOCATION ADDRESS: ``�� �Y� �-' �������(V�ttr�v� t--�-1��EL.#: ti�;� -f{-i -Is2S�'I
MAILING ADDRESS:
OWNER NAME: V'Ji� � (7 Yi-V�G � �l�_S�(Ot, `����f�.�
CORPORATION NAME (IF t�;PPLICABLE): � ' � `
MANAGER'S NAME: �"��\'`v ;r`� Y�� G .r-t c" " ?1, . TEL.#:��:� C1 ��
MAILING ADDRESS:`�l�_�} ��_��('�('YViC���--��, k-� C`r (i,��z�
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CERTIFICATIONS:
The poo ervisor must be certified as a Pool Operator, as eequired by State law. Please list the designated
Pool Operato� )�aIId attach a copy of the certificatioii to diis_fo�m__ , __,_ _
1. —..�� � �
Pool operators must list a minimum of two emp`[oyees cumently certified in basic water safety; staudard First Aid azid
Community Cardiopulmonazy Resuscitation(CPR). Ptease.list these employees below and attach copies of employee
certifications to this form. The Health Department will not use past pears' records. You must provide ne��
copies and maintain a Gle at }�our place of business.
1. 2.
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FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food sercice establislunents are requu-ed to have at least one fiill-time employee who is certified as a Food
Protection Manaeer, as defined 'ui the State Sazutary Code for Food Seivice Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a Sle at y�our establishment.
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PERSON IN CHARGE: �
Each tood establislunent must have at least one Person In Cl�arge �PIC) ou site during hows of opeiation.
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HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich
Maneuver on the premises at all times. Please list your employees tranied in anti-choku�g procedures below aud
attach copies of employee certifications to this forni. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
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RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGISG:
LICENSE REQUIRED FEE PERbIIi� LICENSE REQUIRED FEE PER�4IT= LICENSE REQUIRED FEE PER�fIT r
B&B S55 CABIN S55 _MOTEL S55
INN S55 CA'vLp SS5 _Sl4°I�LtitINGPOOI. S80ex.
LODGE S» �IRAILERPARK SI05 __.__ ,��'HIRLPOOL S80ea.
FOOD SER\'ICE:
LICFNSE REQLIRED FEE PER\9T= LICENSE REQUIRED FEE PER�SIT= LICENSE REQUIRED FEE PER�IIi=
0-100 SEASS S85 _CONiINENTAL S35 NON-PROFIT S30
�>100SEA'IS 5160 �fl-o`t3 �CO�L�fON�'IC. S60 � �O� «'I-IOLESALE S80
RE'I:1IL SER�'ICE: —RESID.ffirCHEN S80
LICENSE REQII[RED FEE PERb1I7# LICENSE REQUIRED FEE PER\-SIT� LICENSE REQL'IRED FEE PER�11T�
_<50 sq.ft. S50 _>25,000 sq.it. 5225 _VENDING•FOOD S25
Q5,000 sq.ft. S30 _FROZEN DESSERi Sd0 _TOBACCO S55
���tE c��ce: sis AMOUNT DUE _ � 220.o0
**"�*PLEA5E 7tiR\O�'ER A\D CO�iPLE'IE O'IHER SIDE OF FOR\�i**"**
ADMINISTRATION
Under Chapter I 52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pernut 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
AFFIDAVIT MUST BE COFvIPLETED AND SIGNED, OR
CERT. OF INSiJRANCE 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
IvivT'EL5�V� Gt�:R iOfiGlhit� �STA�LI�HNIE1tiTS
'I'RANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy shall be
]imited 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 considered 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 inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspechon 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 Heahh Department,Downloadable
Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereaRer, with sample results
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen
Dessert Pernut until the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
NOTTCE: Perntits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIL.TI'P TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOT'EL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS NfAY REQU RE A SITE PLAN.
DATE: i � CY SIGNATURE: ;�i��1Zf�1����f,EC ;�.{
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THI3 CEIXTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AN�GONFER3 NO RIGHTS UPON THE CERTIFICATE FIDLD�R.THIS
CERTIFICATE DOES NOT AFFIRMAi1VELY OR NEGATIVEI.V AMEND, EXTEND OR ALTER THE COV�RAGE AFFOR�EU 8Y THE pOLIGIF3
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEiWEEN THE 153UING INSURER(S), AUTHORI2ED
REPRES�NTATIVE OR pRODUCER,AND TNE CERTIFICATE HOLOER.
IMP�R7pNT: If the certMcape holdsr Is an ADDfTiONAL INSUREO,ehe policyf�)^��st 60 endereed. If SUBRqGATION IS WANED,subjeCL to
the tcrm9 and cenditions W the policy,cerfain pollcles may requlre an entloisemortt. A 9tatemord on ihis certlficaM qoes no!confe�rlgMs m Fhe
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CERTIFICATE HOLDER CANCELLATION
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ACORD 25(2009l08) The ACORD name and logo arp rEgisteretl marlt6 of ACORD
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AATE: November 30, 2010
T0: Acapulcos
FROM: DehbieKleponis
FAX NUMBER: 508-418-5062
RE: Wozk Comp
IVUMSER OF PAGES INCLUbING COVER PAGE: 2
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Certificate attachcd as requcsted.