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Home My WebLink AboutApplication and WC . ,� � � -- �t�o� x ' �� TOWN OF YARMOUTH BOARD OF HEALTI�f'' 1- ° APPLICATION FOR LICENSE/PERMIT-�8 1 �� * Please complete form and attach all necessary doc�i 'ei� "�ecembe IS ZOIQ � � � Failure to do so will result in the retum of your appLYt'dt�on pack . - �"H DEPT. , ESTABLISHMENT NAME: 2 ' .2 � � CS � TAX ID: LOCATION ADDRESS: l2-� Wk i t�t' /�1 rh TEL.#: �(�v- 3/�t� MAILING ADDRESS: �'ain�� OWNER NAME: J CA-X.�.12-c�l� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: � �-(�,9 ��i2,1�.j TEL.#: '7(�- 3juJ MAILING ADDRESS: � Z-�-wk�1�7 �A,� POOL CERTIFICATIONS: �� The pool supervisor must be cerrified as a Pool Operator, as re byfecr St�te law. Please list the designated Pool Operator(s) and attach a copy of the certification to t ' rm. L 2. Pool operators must list a muiunum wo employees cunently cei�tified in basic water sa . standard First Aid azid Community Cardiopulmonary uscitation(CPR). Please list these employees belo d attach copies of employee certifications to tlus form. e Health Department will not use past ��ears' ords. You must provide new copies and maintain e at your place of business. 1. 2. 3. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one full-time employee who is certified as a Food Protection Manaeer, as defined ui the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Heakh Department will not use past years' records. You must provide new copies and maintain a file at your establishment. �. G��% r��,� 2. �J,e�- C�. PERSON IN CHARGE: Each food esfablislunent must have at least one Person In Cliarge (PIC) on site duivig l�ours of operation. 1. �l�dd' h �/L�i 2. ��- �/��c.v�?�a HEIMLICH CERTIFICATIONS: All food seivice establislunents with 25 seats or more must have at least one employee n•ained in the He'vnlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this foim. The Health Department wili not use past years' records. You must provide new copies and maintain A t" your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # X OFFICE USE ONLY LODGI�G: LICENSE REQUIRED FEE PE&bIIT= LICENSE REQUIRED FEE PE&\4ff� LICENSE REQUIRED FEE PERb1[I= _BB:B S55 _CABIN 555 MOTEL S55 _iN2Q S55 _CA143 S�5 _cc•,-G�?"dP.QGP00:. S�Oea. _LODGE S55 �TRAII,ERPARK S105 _\4HIRLPOOL SSOea. FOOD SER�7CE: LICENSE REQUIRED FEE PERMII'= LICENSE REQUIRED FEE PER'�fi'I� LICENSE REQLrIRED FEE PERbfIT# I 0-100 SEAIS S85 I(�OI� _CONI'INENTAL S35 _NON-PROFII' S30 _>I00 SEATS 5160 _CO�LbION VIC. S60 NHOLESALE S80 RETAIL SER�'ICE: —RESID.KI7CHEN S80 � LICENSE REQUIRED FEE PER'bIIT= LICENSE REQUIRED FEE PE&bII7#. LICENSE REQUIRED FEE PERbSII'x _<50 sq.tt. S50 _>25,000 sq.ft. S?25 VENDING-FOOD S25 _<25,000 sq.Tt. S80 _FROZEN DESSERT S40 I'OBACCO � S55 xa�7Ec��cE: s�s AMOUNTDUE _ $ SS.oO ****"PLEASE TLR\O�'ERA\D C014PLE'IE O'IHER S[DE OF FOR3I""""* ,,,_ . 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 CertiScate of Worker's CompensaUon Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFmAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE 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 permits. PLEASE CHECK APPROPRIA'I'ELY IF PAID: YES_� NO '�_4'_�01'ELS�".1`9TD OTp'iEl':,T.Od�G.�3'� �5":ABLISHA:E:�T3 TRANSIENT OCCUPANCI': 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 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 De�artment to schedule the inspecUon three(3)days 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 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. POCiL 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 Yannouth Health 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, or from the Towds 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 revocation of your Frozen Dessert Permit unfil 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 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. IT IS YOUR RESPONSIBII.ITP TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2010. ALL RENOVATTONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY R�E A SITE PLAN. �DATE: C'G��'2�'�(� SIGNATLIRE: � PRINT NAME&TITLE: ��-J'i`� L s�7lvi9�it� (IG�k-�� 10 06'10 s� CHARTIS� RENEWAL BILL �asoN cnRv�u.►w-�oucr:� This is a bili for the renewal of your workers compensation poiicy. If you wlsh to renew your policy, please retum the bottom portlon of this bill abng with a check for the pnemium artauM due to: Ame�ican Ir�tsmational Insurance Companies 22427 Network Place Chicago, IL 60673-1224 Total Premium $1,072 Deposit Due $1,072 If we do not receive your premium payment by 11h5J2010, you wiil not have any workers compensation coverage. Please Retum fhis Portion with Chedc Payable to:AMERICAN INTERNATIOWU.COMPANIE3: REMITTANCE ADVICE TOTAL PREMIUM : 1,072 DEPOSIT DUE: 1,072 � AMOUNT ENCLOSED �� 2� RETURN TO: AMERICAN INTERNATIONAL COMPANIES JASON CARVALHO 22427 Nehwrk Place 311 RTE 28 Chicago, IL 80873-1224 . W YARMOUTH, MA,02673 Renewal Quote : Pdicy#9888487 n� � nnnnnnnnnnnnnoutu�7 7]f1[�r7if1 a nnnnnnnntmann I.