HomeMy WebLinkAboutApplication and WC R' TOWN OF YARMOUTH BOARD OF HEALTH (�[�
APPLICATION FOR LICENSEQ'ERNIIT-2010
* Please co lete form and attach all neces �'�"#y� �1t�: � � %'��19
mp sary dosuments b Dece er 15 2009. ---
Failure to do so witl resuk in the retum of your applicahon p tr ' .
NAME OF ESTABLISHMENT:_ ��/1�ur,�u� �eunrlay ..f'�R-�- TEL. # sZS� �0 8�1T
LOCATIONADDRESS: ��F �aesc /Sr�ob RO•� /nY�l" �A�M.�t, .Y�,a-oz6�-3
MAILINGADDRESS: Sa8 �bctuc /_rce.,vn R�• GJ� Y'�R°n�c� ms��6 �3
OWNER NAME: E�T�L ,�C6/-,t�-n7 Tt�X ID (FEIN or S�l' .
CORPORATION NAME (IF APPLICABLE): �„�� �y�e� ��p. /N'Z._
MANAGER'SNAME; E�Td{-L ��-N TEL. # Sa-��a8�J3'
MAILING ADDRESS: P�tL s� ,qr�-��- .
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.
Pool operators must list a minimum of two employees curr y certified in basic water safety,standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR). Ple e list these employees below and attach copies of employee
certifications to this form. The FIealth De men ill not use past years' records. You must provide new
copies and maintain a file at your place usi �L�/
� �,
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 certification to this application. The HeaUh 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 Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats ar 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-chokmg procedures below and
attach copies of employee certificarions 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 FE£ PERMIT# LICENSb REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
�INN $55 _CAMP $55 �SWIMMINGPOOL S80ea.
_LODGE $55 _TRAILERPARK $105 _WI3IEtLPOOL $SOea.
FOOD SERVICE:
LICENSE REQUIltED FEE PERMIT N LICENSE REQiJIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT#
0.100 SEATS $85 _CONTINENTAL S35 NON-PROFIT 830
>I00 SEATS $160 COMMON VIC. $60 WHOLESAL£ S80
RETAQ.SERVICE: —RESID.KITCHEN S80
LiCENSE REQUIItED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LIC£NSE REQUtRED FEE PERMIT#
_<SOsq.B. S50 >25,OOOsq.ft. $225 ,_VENDING-FOOD $25
�QS,OOOsq.ft. $80 �n—(1�0 _FROZENDESSERT $40 �TOBACCO S55 ��Q_QZ�j
xaME cxaivsE: sis AMOUNT DUE = S /35.po
'•"*"PLEASE TURrT OVER AND COMPLETE OTFIER SIDE OF FORM"••"•
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any license or pernrit 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 AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI,EASE CI�CK
APPROPRIATELY IF PAID:
YES�� NO
MOTELS AND OTHER LODGING ESTABLIS�NTS
TRANSIEN'P OCCUPANCI': For purposes of the limitations of Motel or Hote!use, Transient occupanc.y shall be
limited to the temporary and short term occupancy, ordinazilq and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maurtain a principal piace 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 generall.y be considered Transient.
POOLS
POOL OPENING: All swimming,wading and whirlpools wluch haue been closed for the season must be ins
by the Health Department prior to opening. Contact the Health Departmem to schedule the inspection three( )days
pnor to opening.PLEASE NOTE: People aze NOT allowed to sit in the pool area until the pool has been inspected
and opened.
POOL WATER 1`ESTING: The water must be tested for pseudomonas,total colifoim and standard plate count
by a State certified lab, and submitted to the Health Depariment three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or wvezed within seven('n days of
closing.
FOOD SERViCE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required
Temporazy Food Service Application form 72 hours prior to the catered evern. These forms can be obtained 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 Pemrit uirtil 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 COOHING:
Outdoor cooking,prepararion,or display of any food product by a retail or food service e_stablishmern is prohibited.
NOTICE:Pemuts run annually from 7anuary 1 to December 31. TT IS YOUR RESPONSIBILI7'Y TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2009.
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 SITE PLAN.
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DATE: /� —/�— D`� SIGNATURE: �0�?✓�
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PRINT NAME&TITLE: �C'—�si2 K/,f'A�l/ /�iP�'�7�
09/25/09
�\ The Commonwealth of Massachusetts
Deparhnent of/ndustrial Accidents
N�CI N�
600 Washington Street, 7`�Floor
Boston,Mass. 02111
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