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Home My WebLink AboutApplication and WC ` a � TOWN OF YARMOUTH BOARD OF HEALTH ��s ' � � �� APPLICATION FOR LICENSE/P „ T 0�! � -. , .� ��t 1 �., � t . U i� � * Please complete form and attach all necess " �u�lents'by De r Failure to do so will result in the return you�aplsiication PT ESTABLISHMENT NAME: �� TAX ID: � � � LOCATION ADDRESS: b ��y TEL.#: 7� �� MAILING ADDRES • � � � � � � � �' OWNER NAME: � CORPORATION NAME IF PLIC��j L ��'di y u� �� MANAGER'S NAME: �� w�� TEL.#: k � �d�� MAILING ADDRESS: 3`7 i vu� d�-e.� c� i /v POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - - aua<:#as-eg}Fof tha eer�i�c-�tion to this-form. I. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certif'ied as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 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 file at your establishment. 1. 2. PERSON IN CHARGE: _ Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. 2, HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 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 form. The Health Department will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 __ _CAMP $55 _ _SWIMMING POOL $80ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. 4 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTTNENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq.ft. $50 �a'�� >25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 - _TOBACCO $95 NAME CHANGE: $15 AMOUNT DL1E _ $ S o.o0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 �VORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIG1�D, OR CERT. OF INSURANCE AT1'ACHED OR WORKER'S COMP. AFN'IDAVIT SIGNED AND ATTACHED Town of Yarmouth tases and liens must be paid pr�or to renewal ur issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel 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 OPEIVING: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 prior to opening.PLEASE NOTE:People are NOT allowed to sit m the pool azea 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 ttte 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 OPENIlVG: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to opening. CATERIlVG POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application fonn 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website ac 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 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_Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUII2ED FEE(S) BY DECEMBER 15, 20ll. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, 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 REQUIRE A STI'E P DATE: I I I�� SIGNATURE: � PRINT NAME &TITLE: ��f ��'�� Rev.]0/25/II �� The Commonwea/th of Massachusetts Department ojlndustria/AcciJenls N�CaNrw�aGNs 600 Woshington Street, Y"F/oor $oston,Mqss 02111 . . �Worlcers'Compeesallos lasdnaee AftldaviF,� � � . , . . .. . . . . ... "•.1��: . '}' it. _. naroe� 1 VG'1/ � •.. �-- Gi�� . ��a �-� ' L� °'1 � Sm« �� D� � on�a 7(00-- � wo.k sire tocation rruu adaressl: ❑ [am a homeowner peiforniing all wak myself. ❑ I a sole pmprietor and have no one wodcing in any capaciry. 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