HomeMy WebLinkAboutApplication and WC _ BRss R�vEtt MeRcaN�n�E.
`-�,�� TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT- 2011
�� * Please complete form and attach all necessary documents li�ec�b�1 f 0. �
Failure to do so will result in the retum of;your�pplication pac cet. � - � 4 Z O�O z
ESTABLISHMENT NAME: SS R<JG� K�✓�,�I' TAX ID: � � ���-
LOCATION ADDRESS: 2 � ad �Pa. qy L.#: cS d'' 7�CU /
MAILING ADDRE�S; D ) pJ �
OWNER NAME: J`T� d
CORPORATION N E��PLICQ.�LE : i -
MANAGER'S NAME: •cii°�<, ���d`� TEL.#: �2.�_
MAILINGADDRESS: icle„� vas„ hc/{- U/�/U
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POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a mnlimum oftwo employees cun•entiy certified in basic water safety, standard Fn•st Aid and
Community Cazdiopulmonary Resuscitation(CPR). Please list these employees betow and attach copies ofempioyee
certifications to tlus form. The Health Department will not use past years' records. You must provide ne�r-
copies and maintain a 51e at your place of business.
l. 2.
3. 4.
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 ofcertification to this application. The Health Department will not use past��ears'records.
You must provide new copies and maintain a file at ��our establishment.
I. z
PERSON IN CHARGE:
tach Yood establislunent must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food seivice establishments with 25 seats or more must have at least one employee uained in the Heimlich
Maneuver on the premises at all tnnes. Please list your employees tranied in anti-chokn�g procedw•es below and
attach copies of employee certificatious to this forni. The Health Department���ill not use past years' records.
You must provide new copies and maintain a 61e at your place of business.
1. 2
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PER�fII'� LICENSE REQUIRED FEE PER\qIT� LICENSE REQUIRED FEE PER�IIT�
_B&B 555 _CABIN S55 _MOTEL S55
—�� S�s _CAbiP S5� _SR'I�LYINGFGOL 58Gea.
_LODGE • 555 _1RAII,ERPARK SI05 !�y'HIRLpOOL SSOea.
FOOD SER�7CE: .
LICENSE REQU[RED FEE PERbIIT 4 LICENSE REQLnRED FEE PER�4I1"= LICENSE REQUIRED FEE PERbIIT�
_0-100 SEAI'S S85 _CONTINENiAL S35 NON-PROFI7 S30
_>100 SEATS 5160 _CO�ION VIC. S60 R'HOLESALE S80
REt.11L SER\'ICE: . —RESID.KIICHEN S80
LICENSE REQUIRED FEE PERVIIr# LICENSE REQUIRED FEE PER\4IT- LICENSE REQC'IRED FEE PER�41T#
�<i0sq.t1, S50 '{�(���3� _>?S,OOOsq.B. 5225 VENDING-FOOD S25
_<2i,000sq.ft. S80 _FROZENDESSERT S40 iOBACCO S55
SA�iE CHA\GE: Sli AMOUNT DUE _ $ 50 .00
**'""PLE.ISE TtiRC O�'ER A\D CO�IPLEI'E OTHER SIDE OF FOR�I*'*"*•
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pzrcnit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STAT`E WORKER'S COMPEN$ATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
\ � , . ,
CERT. OF INSURANCE ATTACIIED Y
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pemuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES ° NO
Mt?TEI.S:�?lTF3 �3T'��R L(DD�1:ST� ESTAI3LIS�lYI�.lY'�'S : -
TRANSIENT OCCUPANCY: For purposes ofthe 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 ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
a�gregate of not more than ninety(90) days within any six(6) month period. Use of a guest unit as a residence or
dwel}ing unit shall not be considered transient. Occupancy tha? 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 Heakh Department prior to opening. Contact the Health De�artment to schedule the inspection 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 wliform and standazd plate count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSINGc 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 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 Town's website at www.varniouth.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 Pemut until the above terms haue been met.
OUTSIDE CAFES:
Outside cafes{i.e., out_door seating with waiter/waitress service),must have vrior agprov�l from the Board QfHealth.
OUTDOOR COOKING:
Outdoor cooking,prepazation, 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 RESPONSIBILTI'Y TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MiJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY R QUIRE A SITE LAN
�DA7"E:_ �I ��b SIGNATURE: C..– � � _
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TMIS CERTIFICATE IS ISSUED A9 A MATTER OF INFORMATION ONLY ANO CONFER3 ND FiIGXT$UPON THE CERTIFICAT HOLDER.
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- sub�ect to the terms and eondtlions of the pcilcy,eertgln polklp may requte en endor5ement. A stalement on thls eerlHkate
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