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Home My WebLink AboutApplication and WC r TOWN OF YARMOUTH BOARD OF HEALTH �`�� B�� APPLICATION FOR LICENSE/PERMIT- 2011�� , _ �. �� ! � �.� : * Please complete form and attach all necessary docume�ts�y�ecnmber 5 ZO 0. Failure to do so will result in the retum of youF apglication packet. � �''-' ��'� ESTABLISHMENT NAME: ` iY(lEC� c�' I��L/C-l�-i� TAX ID� �' MAILING ADDRESS: �C'X1M� ` OWNER NAME: � 1�crN C�W�r�' CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME:_ TEL #� 0��7�� MAILING ADDRESS: ��I Y1��7 rv C� i.v--1 POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attacl�a capy of the r.ertification to this forn�. 1. 2. Pool operators must list a minimum of two emp]oyees ntly certified 'm basic water safety,staudard First Aid and Community Cardiopulmonary Resuscitation(C . lease list these employees below and attach copies ofemployee certifications to this fonn. The Health artment wilt not use past years' records. You must provide ne�r copies and maintain a tile at y� ace of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establishments are required to have at least one full-tuve employee who is certified as a Food Protecrion Manaeer, as defined in the State Sanitary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Heaith Department will not use past,years'records. You must provide new copies and maintain a file at your establishment. 1. �t� �C-�l L 1 2. c ��,�i,� (��-t.4'l'c r�, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hom�s of operation. 1. �� 'l � I��/�i 2. ��— ��"31�� HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee n•ained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokine 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 �te at ,your place of business. 1. Z 3. 4. RESTAURANT SEATING: TOTAL # � / OFFICE USE ONLY LODGI\G: LICENSE REQL7RED FEE PE&'b1II'� LICENSE REQUIRED FEE PER\4IT� LICENSE REQUIRED FEE PER�IIT z _B�B S55 _CABIN S55 _�10'IEL S55 —� S�� C�� S�' _S\�'I�IlVIINGPOOL S80ea. — ____-_--� _LODGE S�5 _TRAII,ERPARK S105 _RZ-IIRLpOOL S80ea. FOOD SERVICE: LICENSE REQL9RED FEE PERbIIT a LiCENSE REQUIRED FEE PER'�fIT= LICENSE REQUIRED FEE PER�IIT� I 0-100 SEATS S85 � G'� _CONTINENIAL S35 _NON-PROFII S30 _>IOOSEATS S160 �CObLbIONVIC S60 �j—Ow _NHOLESALE S80 RE'LAIL SERi7CE: _RESID.KIiCHEN S80 LICENSE REQUIRED FEE PERVIII'� LICENSE REQUIRED FEE PERbtI7= LICENSE REQUIRED FEE PER11I7= _�50 sq.ft. S50 _>25,000 sq.8. 5229 VENDINC,-FOOD S25 _QS.00Osq.ft. S30 _FROZENDESSERT S40 TOBACCO S55 �a�zE cx.�scE: sis AMOUNT DUE _ $ I 4 5.00 *""*pLEASE'IGR\OVER ASD C01iPLETE OTHER SIDE OF FOR3I*""** � j _ 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 ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK APPROPRIATELY IF PAID: YES�, NO ,_, MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OGCUPANCI': For purposes ofthe limitations ofMotel 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 of residence 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 sha11 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 swimrrung,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.PI.EASE NOTE: People are NOT allowed to sit m the pool azea until the pool has been inspected and opened. POOL WAT'ER 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 wvered within seven(7) days of ciosing. - FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspectedby the Health Department prior to opening. Please contact the Health Department to schedule the inspectron 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 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 Aealth Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untd the above terms haue been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILTI'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, 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 RE E A SITE PLAN. DATE: �Q�,f�(� SIGNATURE: T PRINT NAME&TITLE: �{1Ji— (,fil�� v�l/,�..✓ 10 06 10 CHARTIS� RENEWAL BILL JASON CARVALHO-POLICY:9886467 This is a bill for the renewal of your workers compensation policy. If you wish to renew your policy, please retum the bottom portion of this bill along with a check for the premium amount due to: American Intemational Insurance Companies 22427 Network Place Chicago, IL 60673-1224 Total Premium $1,072 Deposit Due $�,p72 If we do not receive your premium payment by 11h5/2010, you will not have any workers compensation coverage. Please Retum this Portion with Check Payable to:AMERICAN INTERNATIONAL COMPANIES: REMITTANCE ADVICE TOTAL PREMIUM : 1,072 DEPOSIT DUE: 1,072 AMOUNT ENCLOSED �C' .�2 � RETURN TO: AMERICAN INTERNATIONAL COMPANIES JASON CARVALHO 22427 Nehvork Pface 311 RTE 28 Chicago, IL 60673-1224 W YARMOUTH, MA, 02673 Renewal Quote : Policy#9886487 �, � nnnnnnnnnnnnnqna��7 i.�n��m.n a nnnnnnnntimann �.