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HomeMy WebLinkAboutApplication and WC ' ^� �� TOWN OF YARMOUTH BOARD OF HEALTH r'�'— � .. �,� � i�l� ,i�i , APPLICATION FOR LICENSE/PERMIT,��011� ` � �� .� f ' ., � �...a .. . . � t . .V * Please complete form and attach a11 necessary docusii ` er I S 2�10. Failure to do so will result in the return of yqur�pflCation ac �ALTH DEPT. ESTABLISHMENT NAME: �C',Lei''S �AC,�q 2 Sf d/'-� TAX ID: � LOCATION ADDRESS: S5 �t �9� , Gt>CSt Y��"�''ioG2t6� /YitJ TEL.# 5d�')775- d6// MAILING ADDRESS: SS �� 02� CcJPJ'� /�lrlrtO�e� y/�!i} 02G�� OWNER NAME: C'�2 L cG[�/-rni~t CORPORATIONNAME ( APPLICABLE): GU/Uohf �S �"��S �n� MANAGER'SNAME: C6tc� L Jh� r -ti TEL.#: 5�8 77S—C�6// MAILING ADDRESS: 3 // f-i5� �h /���/l�s O�t /1Tfj �Z63 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. I. 2. Pool operators inust list a mniimum of two employees cun•ently certified in basic water safety,standard Fnst Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee �:, certifications to tlus foim. The Health Department wilt not use past years' records. You must procide new ;:; copies and maintain a tile at your place of business. i. Z_ 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food sernice establislunents are required to have at least one fiili-time employee who is certified as a Food Protection Manager, as defined ui the State Sanitary Code for Food Seivice Establislunents, 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 estabtishment. 1. 2, PERSON IN CHARGE: Eacn food estaousiunent uiust Iiave at Ieast one Ferson in Charge (PIC) on site duruie hours of operatioi�. 1. 2 HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained 'ui the Heimlich Maneuver on the premises at alt tnnes. Please list your employees trauied in anti-chokine procedures below aud 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 51e at your place of business. 1. 2 3� 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PER�II'I a LIGENSE REQUIRED FEE PER�41I'� LICENSE REQUIRED FEE PER�iII'r _B&B S55 _CABIN S55 bf07EL S55 —� $5= _r`�\?P c:` _S`.l'I.".�:IN�?'GCL SbO:a. _LODGE S55 �TRAILERPARK 510� � � IiZIIRLPOOL S80ea. FOOD SER\10E: LICENSE REQUIRED FEE PERNIII'� LICENSE REQUIRED FEE PER\�fIT F LICENSE REQUIRED FEE PER�III'_ _0-]00 SEAl"S S85 _CONI'IIVENTAL S35 NON-PROFIT S30 _>IOOSEA'IS S160 _CObZYION�7C. S60 �6fiOLESALE SSO REI'AII.SER�'ICE: —RESID.ffi7CHEN S80 LICENSE REQUIRED FEE PERbiIr= LICENSE REQUIRED FEE PER�IIT- LICENSE REQUIRED FEE PE&�IIT� I <SOsq.ft S50 II'b�il _>25,OOOsq.ft. S22i VENDING-FOOD�S25 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 �IOBACCO S» �—O�S �.�«E c��cE: s is AMOUNT DUE _ � (p S •o0 . ""***PLEASE TLR\OVER A\D COSIPLEI'E OTHER SiDE OF FOR�i**"** 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 INSURANCE ATTACHED� OR WORKER'S COMI'. AFFIDAVIT SIGNED t1ND ATTACHED Town of Yarmouth taaces and liens must be paid pr' r to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MO'I'ELS AND OTHER LODGING ESTABLISHMENTE 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 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 inspection tl�ree(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WA'I'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. YIDOL Ct.GSI1VG: Ever}�outdoor in ground swimming pool must be drained or covered within seven(7) days of ciosing. 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 inspection 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 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 Pemvt until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approvat from the Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOT'ICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIKED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RFyQUIRE A,$ITE PLAN. � �aTE: I/ - Z - /O siGrrart�: (� ,�� � C ���'l�� PRINT NAME&TITLE: UVC��/L /"i (��IZ��N —� 10'06'10 Noa. 4. 2Q10 11:41AM No. 0214 P. 1 CERTIFICATE OF LIABILITY INSURANCE °"ii�`o4iio Proauar 1N15 CERT�ICATE I5 ISSUED AS A MATTER OF � WmFBoihsklrems�eApancy . � INF0f3MATIONIXVIYANDCONFERSNDRIGFITSLIPONTHE 371 PlymoWh Slreel CERTIFIGATE I10LOER. TFiIS CER7IFICATE pOES NOT ��Mp pp� � � AMEND, EXTEND OR ALTER hIE COVERAGE AFFORDED BY THE POLICtES BELOW. NSURERS APPORDING COVERAGE NAIC i/ �^�� WSURERA MARa[ail�Mrc�aMSWCGrau Inc. 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