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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALT � ` aN S�ON � � APPLICATION FOR LICENSE : 2� �� :;� ��3� > NQV 10 2011 * Please complete form and attach all necess ' doc� t -byD� ember IS 2011. Failure to do so wIll result in the re f your applicatio pa LTH DEPT. ESTABLISHMENT NAME: ��A�)h 1I � .�o Ga,,,,-,� TAX ID• IACATIONADDRESS: Na�C�IrR C�/� �iT/�wm Rr0 .�; Dw��..�ic TEL.#: S6� ' .3�PS-_?/�� MAII.ING ADDRESS: Pr� CS / c o PN;v ts Yn A n a L 6 a OWNER NAME: I.�1 �i 1 �'u,., �t- �;,�,n�a c�'✓�� 14 J�1 CORPORATION NAME(IF APPLICABLE): J-1 �i r�h�.i i_c 2-� Cr,�ar, MANAGER'S NAME: Wi'lli��arv. �'13 �hi TEL.#: SDF' - "/7b-o�ll�CJ MAILING ADDRESS: 1�() �S� S �enrnll c rr, r� n�b br1 POOL CERTIFICATIONS: Thepool supervisor musE ber.ertified as a Peoi Opeeator-,ac Fequiredbg�tate law. g�ease list th��si�at�---- - Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary 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-ne�cnni�and_maintain a file ak.your pla��£hu�in€s�- - --- ----------__ __ _ 1. 2. 3. d ' q. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze required to have at least one full-tnne employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certif"ication 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.�( ,Z+ � i��r�!?c.�Q n) 2. �-1 nl h�, �'Ia/�� rv PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1. l.i )i !� i Arr. �C3UIQIJ 2. HEIMLICH CERTIFTCATIONS: 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 certif'ications 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. � .- . RESTAiIRANT SEATII�TC:� TOTAL#s _.__� OFFICE USE ONLY LODGING: LICENSE REQUII2ED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMTT# _B&B $55 _�ABIN_ . ___ S55 i..-- �MOTEL ---$45 = _INN $55 _CAMP $55 _SWIMMINGPOOL $80ea _LODGE $55 _TRAII,ERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEAT5 $85 ��"OI{o _CONTINENTAL $35 _NON-PROFIT $30 _>100SEATS $160 _COMMONVIC. $60 _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMTT# _60 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.fi. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $IS AMOUNT DUE _ $ H 'rJ' •�O sttztpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*�•* ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth 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. AFFIDAVTI' 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 ,T NO MOTELS AND OTHER LODGING ESTABLISHNIENTS TRANSIENT OCCUPANCI': 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 demonsuate that they maintain a principal place of residence elsewhsre.Transient oceupancy shall generally refer tn contiaeo�s occ�apancy of not more than thirty{30)days,and an agg�egate 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. a 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 three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pooi 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 three (3) days prior to opening, and quarterly thereaftez POOL CLOSING: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 inspection three (3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yazmouth must notify the Yazmouth 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 Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certif'ied 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/wailress service),must have prior approval from the Board of Heaith. 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 January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S) BY DECEMBER 15, 2011. AT,i" RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMIvIENCEMENT. RENOVATIONS MAY REQUIRE A STI'E PLAN. DATE: ��f/ SIGNATURE: � (��,,,,,,,,_ PRINTNAME&TTl'LE: 1—�Nb� �I�Ulen� — � ��.�orzsni � i � � The Commonwealth of Mossachuset�s Department oflndustria/Accidenfs N/fe/Nrws�MMs 600 R'oskington Street, �`"F[oor . Boston,Moss. 011ll Workers'Compe�satios Iwsoraece ABtd�v[I: , . . r . •.. t' ..^+. , AmNea�t hhrw�tlr• Pbare PR11V?�led6h •� naroe� H�H �N i C S o �PX)m . . . _ ._ . . . . . . address: _�Q �S � --- --- �� . .. c� ��. l7�7v lV�S state: I�'1 �"� zio: ��) ohone A S Q�' 3 0 S;�i �� work site location(full addressk ❑ I�a 6omoownu perfoiming all wo�lc mysetf. ❑ I�n a sole proprietor and have no a�e wodcing in m�y capacity. . . . _.�am ao em lo er idin workecs' - -oe foY- -an ecs w ' un iims.. 6 ... .. _... _.__� --- --- .. ._._. P Y Pnv 8 compensa� mY P�%' �o�C�nB Jo � con t TP � addRa- r M• �., a 50Ek�8-$' 30 /o?(�/Gl . .-.� � ,:M. , --.,,,....,_.�,.:..,::�-•--'��"'-_.._.3-,..-.:.�.,.is.-:L:,--+.�a4-w�+�,� t-,. ,��:.-A _ �[]��I am a sole propndor,ge�eral eo�tnctor,or 6omee�ner(cnde n+k)aed have hued rhe conaacwea Lsted�-'lie�wln have �. t6e following workas'comPensation Puliasr.. ... �, ..t� ; . . . .. : ,... . _. . . . . . -:�. ced�r.v�• . , . . . . . . . . . _. .. . . _ ._ ._. ad�ar .. citv' oYaeeM: lewa�ee ea p�tlei N . . . . . . �auv�e• addrm- _ ._._ . __ ._ _�__-.. � _. -__ .: _ _ . ._ . _. _. .' -.__—�_ _ eM: . . _ . . _. . o�e�e M: _. _ . __ . ._ . . . idea�oe cu o�tle�N ,ur�rrrrrr..ere..i r.��+a�e..�..�..�a�r me s�w zsw.tnsc�isi e.k.a rn�e.p.,wi...r�.rr�ww.t.e.��nsi.srr..w e�eyean'leq�r6w�estnwNadN�nAl6et�daSTOtWOIUCORDBRud�meMSIM.Mtdqgvatse. t�dtlN• eapy�tUb thEeaeM�y 6e finr�rded r t!e Omte dlaveYlpllw NHe.DiA hr h�vfde wmnYr. /do IYere6y certlfy rnder Ms palws w/O/�N��+�Ph/�7W�Me fwfenr�low predlel oborc b trre ad oermt Sigoatum��L�( .' .:..L'�+in.Y., � �� ... � . .0.h . �.J�l'(S..'�%l . ._ . . . e�;m� l. ir�ala 1.. �k'3(�Yth� , eno�k Sl�� - 77G-a�o , omdd ox..y-�-� a..ef anle r lN..re,u ee arvpefd M dlr�oraw..�cid --. � _ . . . . ... . _ . . . .� . , � .� ��., � . . cN7 x Nwo: -.. . . . . . � . .. � / �. . pvdHticeae X � .�pdoe�t . . 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