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Home My WebLink AboutApplication and WC � � � 3EceEi2s TOWN OF YARMOIITH BUARD OF HEALTH a _ _, APPLTCATION FOR LICENSE/PERM[�- ��,{'�' �- ;' �;N' * Please complete form and attach all necess�ry de " ;' s �]�ec��ber1. 2 09 , , F a i l u r e t o d o s o w i ll r e s u l t i n t h e r e t u r p g f y�n c�a tion p�c e t. ,._- NAME OF ESTABLISHMENT: �3f CkE,e`S //!,'CkA GE ST012F TEL. # .�UB �7,�- (/ LOCATION ADDRESS: 5y� iP0 uTE „2� Gv.�..,�7' �/i4RM 6 UTE! M,� C��d�3 MAILING ADDRESS: OWNER NAME: GH�R�/[ �KN�PI 1'�l�C'A�-KE/' T X ID (FEIN or SSNL / CORPORATION NAME (IF APPLICABLE): 7"Gf/1u�NT �Oik�TS T/t/C � MANAGER'S NAME: �.NF/Z�/ G r>�Nn/.c�/�J M`CAQ,P_�/i/ TEL. #�� j/b -/L(o S MAILING ADDRESS:_ �.3/ ,�'��v FiSk LRNf aENN�S pd�2T ,/� L��S c� POOL CERTIFICATIONS: T6e pool supervisor must be certified as a Pool pperator,as required by State law. Please list the designated _P_ool Operator�s) and attach�copy of the certificarion to this form. 1. 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 ofemployee certifications to this form. The Health Department wiil not use past years' records. You must provide new copies and maintain a Cile 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 certified as a Food Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificarion to this application. The Health Department will not use past years' records. You must provide new copies and maintain a t"ile at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list yow etrployees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Departmeut will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. TtESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LIC�NSE REQUIRED FEE PERMI7'# LICENSE REQUIRED FE6 PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL S55 _INN $55 _CAMP $55 _SWIMMQVGPOOL 580ea. _LODGE $55 �TRAII,ERPARK $105 _WHIRLPOOL SSOea. FOOD SERVICE: LICENSE REQUIItED FEE P$RMIT# LICENSE REQUIRED F£E PERMIT# LtCENSE REQUIRED FEE PERMIT# _0.100 SEATS S85 _CONTINENTAL %35 NON-PROFIT S30 >100 SEATS $160 _COMMON V[C. $60 _WHOLESALE $SO RETAII,SERV[CE: —RESID.KITCHEN S80 LICENSE REQL7IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiC£NSE REQUIRED FEE PERMIT# I 60 sq.ft. S50 �l0�OZy >25,000 sq.ft. $225 � _VENDING-FOOD $25 _QS,OOOsq.ft. $BO � _FROZENDESSERT $40 �TOBACCO $55 �-618 NAME CHANGE: 315 AMOUNT DUE _ $ I 0 S. o 0 *"*""PLEASE TURN OVER A1VD COMPLETE OTHER SIDE OF FORM"*'w* -� � - anrmvis�xazzox Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth 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 COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABIJSHII�IENTS T1tANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiern 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 maimain a principal place ofresidence elsea+here. Transient occupancy shall generally refer to corninuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any s'vf(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 bcen closed for the season must be inspected by the Health Department prior to opening. Contact the Health Departmern 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 coliform and standard plate count by a State certified lab, and submitted to the Health Department tluee (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)d�ys of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must norify the Yarmouth Heahh Depaztntetrt by the required Temporary Food Service Application form 72 hours prior to the catered event. These foims can be o ' ed at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 ofHealth. OUTDOOR COOKING: Outdoor cooking,prepararion, or display of any food product by a retail or food service establishmetrt is prohibited. NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RET[JRN TF�COMPLETED RENEWAL APPLICATION(S)AND REQilIRED FEE(S)By bECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Ti-�E BOARD OF HEALTH PRIOR TO COMMENCEMEN"I'. RENOVATIONS MAY REQUTRE A 3ITE PLAN. 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