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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF �- �g; s �� APPLICATION FOR LICENSE/PERM � '� 1�� ^ �� v ~T � �, �� '� FEB 27 2012 •Please complete form and attach all necessary doc ts b cem r IS 2 10. � Failure to do so will resul[in the retum of your applicat�on pac et. � .... . . -_tiL.�- I . � .�. �. LOCAT[ON ADDRESS: � S CtuC..�tL L�. \LzrriiU U'H�nu c�7'EL.#: 5'�8 3(0 7".S�4'7 . MAILING ADDRESS: �4rit a- OWNER NAME: QI�C. O nS CORPORATION NAME(IF APPLICABLE): o � �7 MANAGER'SNAME: NQ � YlS TEL.#: MAILINGADDRESS: FC S2tN � armn� ort 011o7 POOL CERTIFICATIONS: � The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the desigoated Pool Opeiator(s)aud attach a copy of the certi£cation to this form. . l. 2. Pool operators must tist a minimum of two emptoyees curren[ly certified in basic water safety,s[andard Firs[Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below aod attach copies of employee certifications to this form.The Health Department wfll not use past years'records. Yoa must provide new copies and maintain a file at your place of business. I. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager,as defined in the Sta[e Sanitary Code for Food Service Establishmen[s,105 CMR 590.00(l. Please � attach copies of certifica[ion to this application. The Hea►th Department wiR not use past years'records.Yoa must provide new copies and maintain a file at your establishment 1. 2. PERSON IN CIIARGE: Each food establishmen[must have at least one Person[n Chazge(PIC)on si[e during hours of operafion. 1. 2. HEIML[CH CERTIFICATIONS: All food service estabiishments with 25 seats or more mus[ have at leas[ one employee trained in the Heimlich Manwver on the premises at all times. Please lis[your employees trained in anti-cholung procedures below and attach copies of employee certifications to this form. T6e Health Department wID uot use past years'records. You mnst provide new copies and maintain a tlle at your place of busincss. I. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFF[CE USE ONLY �o�wc: LICENSE REQ[IIRED FEE PEAMIT# LICENSE REQUIRCD FEE PERMIT# LICENSE REQUtRE� FEE PF.RM[7'# _B&e $55 _CAB[N $55 _MOTEL $55 _INN S55 _CAMP $55 _SWQNMINGPOOG SSOea LODGE S55 '1'RAILERPARK $IOS WHIRLPOOL $SOea FOODSERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT N _0.100SEAT5 S85 _CONTINENTAL S35 _NON-PROFiT S30 >1005EA7S SI60 COMAiONVIC. S60 WHOLESALE S80 ��- � ( RETAII.SEI2VICE: LRESID.KITCHEN S80 :J�—��I LICENSEREQU➢tED FEE PF,RMI'P# LICENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMITN _<SOsq.ft. $50 _>25,OOOsq.ft. 5225 _VENDING-FOOD S25 _QS,OOOsq.R SSO —FAOZEN DBSSERT S40 _TOBACCO $95 rvnMecnnrvcs: sis AMOONTDOE = S 4'H��;CriJ **'••PLEASE TURN OVER AND COMPLETE 07'llER SIDE OF FORM••"• � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth is now required to hold issuance or re�ewat of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insumnce. THE ATTACHED STATE WORKER'S COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR - CERT.OF INSURANCE ATTACHED_ OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY/F PAID: YES NO MOTELS AND OTHER LODGING ESTABLISNMENTS TRANSIENT OCCUPANCY: For purposes of the limitatio�s of Motel or Hotel use,Transirnt occupancy shall be limited[o the tempornry and short tecm ocwpancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstra[e[hat 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 aggegate of not more than ninery(90)days wi[hin any six(6)mon[h period. Use of a gues[unit as a residence or dwelling uni[shall not be considered tlansient. Occupancy that is subject to[he 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 OPEHING:All swimming,wading and whirlpools whichfiave beeu closed for the season must be inspected by the Health Departmrnt prior ro openmg. Contact the Health Deparhnent to schedule[he inspec[ion Uuee(3)days pnor to opening. PLEASE NOTE: People are NOT allowed to s�t m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total wlifotm and standsrd plate count by a Siate certified lab,and submitted to t6e Health Departrnent three(3)days prior to openiug,and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOODSERVICE SEASONAL FOOD SERV[CE OPENING: � All food service estabtishments must be inspected by[he Heal[h Department prior to opening. Please contact the Health Departrnen[ro schedute[he inspec[ion three(3)days prior to opening. CATERING POLICY: An}rone who ca[ers within[he Town of Yazmouth 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[he Health Department,or from the Town's website at www.yannouth.ma.us under Health Depaztmeni,Downloadable Foans. 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 revceation of your Frozen Dessect Permit until the above terms 6ave been met. OUTSIDE CAF$S: Outside cefes(i.e.,outdoor seating with waiter/waitress service),must have prior approvat&om the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILII']'TO RE7IJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER I5,2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'I'ING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � �2 �2- SIGNATURE: �/ PR1NT NAME&TITLE: �.1 A'rvl'�.`�- C'�N S x�.mrovu � The Commonwealth of Massachusetts Department of Industrial AcciJents N�NN� 600 Washirtgton Sheet, Y"F[nor Boston,Mass. OZIII Worke�s'Compeasatioe Iwannm AflidavG: �f i�atln• Mn�e PR�V7'kai6lt name: N�'T��n��Pa ns S address: `6 5 fi++�/LK-4�--12.i�- ciry ��'2�-��/��Y�2� state: N�.h- zin: C3ZG�-TolwntN ��&� 3�,""7 ' �S�-1� work site location(futl addressl: ❑ I am a homeowner performing all wak myself. �I am a sole proprietor azd have no a�e wodcing in ariy capaciry. ❑ [am an anployer providing workecs'compe�ation for my emQloyees wo�king on this job. comwer me- ad�as• efh- oYme N' Ia�va�oe es. oatle�B � ❑ I arn a sole proprie[or.ge�eral ewtrxMr,or Yomrnw�er(cirde one)and have ttired the conhxtas listed below who�have the following workers'compencation polices: eomouv ude• ad�aa• cltv' olase A• Issm�ee eo. noLte.# Wnouv l�e• l�f• �� K^!f0. 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