HomeMy WebLinkAboutApplication and WC j =. B. R. BEqC.N coNc�ssioa
TOWN OF YARMOUTH BOARD OF HEAI:TH
APPLICATION FOR LICENSE/PERNIITE-,3t 'G3 I�s G�'C�'��I C�DD
*Please complete form and attach all necessai}«d � 'by �VI
F a i l u re to do s o w i l l re s u l t in t he r e t u r�q f$�our app lica tio p �h ��P-�
NAME OF ESTABLISHMENT:�5g55 z(✓�rt f3ENc r� co�✓arss/o n/ TEL. #508-�G-�O
LOCATIONADDRESS: �s /1��.L ef�vct�
MAILING ADDRESS: �D �3ox Ssi S r�,E.v��✓rs M A bd.�� O
OWNER NAME:NYAdN�S t Ck citEA�n TAX ID (FEIN or SSN�- �
CORPORATION NAME (IF APPLICABLE): �
� MANAGER'SNAME: �3/C� �3uR�/ TEL. #Z'fy-f<Sf7-/l3/
MAILING ADDRESS: se M iE
POOL CERTIFICATIONS:
TLe pool aupervisor 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 certificarion to this form.
L 2. _
Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and
Commwuty Cardiopulmonary Resuscitarion(CPR). Please]ist these employees below and attach copies of em lo
certificarions to this form. The Health Department will not use past years' records. Y ��v
copies and maintajn a file at your place of business. `
1. a. N V 2009
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is cenified 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 applicarion. The Heahh Department will not use past years' records.
You must provide new copies and maintain a file at your estabGshment.
1.w��cf9Nl E3u2ti 2. LrNOi9 �'3�t/��✓
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 7 �'v ; �� 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee traincd in the Heimlich
Maneuver on the premises at all times. Please list your en loyees mdined in anti-chokwg procedures below and
m
attach copies of employee certificarions to this form. T6e ealth Department will not use past years' records.
You musf provide new copies and maintain a file af your place of business.
L 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIR£D FEE PERMIT#
_BBcB S55 _CABIN S55 _MOTEL S55
�II3N - $55 � _CAIvSP $55 �SW1MbIINGPOOL $80ea.
_LODGE $55 _TRAII.ERPARK $105 _WFIIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQUIItED fEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT k
�0-100 SEATS 885 �L 10��1 _CONTINENTAL S35 _NON-PROFIT S30
>I00 SEATS $160 _COMMON VIC $60 �WHOLESALE $80
� RETAII.SERVICE: —RESID.KII'CHEN 380
_
LICENSE R£Q[IIItED fEE PERMIT# LICENSE REQUIltED FEE PERMIT# LIC£NSE REQUIRED FEE PERMIT#
_c50sq.R $50 >25,OOOeq.R. 5225 _VENDING-FOOD S25
_Q5,000 sq.ft. �� ��580 � � �� � ��FROZEN�DESSERT $40 � � � � TOBACCO $55
xa�CHnxGE: sts AMOUNTDUE = S �S.Oo
•"'"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""•*
4 . }'.
ADMINISTRATION
LTnder Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal
of any license or pernut to operate a busittess if a person or company does not have a Certificate of Worker's
Comp�ttsatit5n Insurance. 1� ATTACHED STATE WO1iKER'S COMPENSATION INSURANCE .
AFFIDAVIT MIIST BE COMPLETED AND SIGNED,OR i
CERT. OF INSURANCE ATTACHED _ II
OR �
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED� I
Town of YazmouW taxes and liens must be paid p or to renewal or issuance of your permits. PLEASE CHECK II
APPROPRIATELY IF PAID:
YES NO I
AIOTELS ANB OTHER LODGING ESTABLIS�NTS ,
Ti2ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be I
limited to the temporary and ahort term occupancy, ordinarily and customazily associated with motel and hotel use. I
'l,!faais'"T�tit'accnpa�e.must have and be able to demonstrate that they maintain a principal place ofresid�ce dsewhe,re.
'�ransient ocxupaz'tcy slial! generally refer to corninuous occupancy of not more than thirty (30) days, and aa
aggrega�of not more than ninety(90) days within any six(6)month period. Use of a gueat unit as a residence or
dweilih�g uurit'sliatt not be considered transient. Occupancy that is subject to the collection of Room Occupancy I
Exctse; a�defined ia;1vI�G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. I
_ . __..___. .,_..., I
POOLS II
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be' p
by the Health Department prior to opening. Comact the Hea1th Deparhttem to schedule the inspectiontl�e(3)d�ays
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool area wrtil the pool has bcen inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate couut
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(9)days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town ofYarmouth must norify the Yarmouth Health Departcnent by Sling the required
Temporary Food Service Application form 72 hours prior to the catered evem. These forms can be obtained at the
Health Deparnnent.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health I
Department. Failure to do so will resuk in the suspension or revocation of your Frozen Desaert Pennit wrtil tha �,
above terms have been met.
OUTSIDE CAFES: '
Outside cafes(i.e.,outdoor seating with waiterJwaitress service),must have prior approval from the Board ofHealtb. ,
OU'IDOOR COOHING: �
Outdoor cooking�preparation,or dis�lay of any food product by a rekail or food seiviice establishme�rt is proLibited. ;
NOTiCE:Pernuts run annually from January 1 to December 31. TT 7S YOUR RESPONSIBII.ITY TO RETIJRN II
Tf� COMPLETED RENEWAL APPLICATION(S)AND REQLTIltED FEE(S)BY bECEMBER 15, 2009. �
ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENP, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQ A SITE P .
DATE:����" 49' SIGNATURE:
PRINT NAME&TITLE: !.✓<<��➢in c�L Rni yILES:
09/25/09
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The Commonwea[th of Massachusetts
DeparYment of Industria/Accidentc
I NMC/N/O�
I 600 Washington Sdrey �"'Floor
Boston,Mass. 01I11
Werlcers'Compeasatioo Im�nnee AiSdavkt Baildiog/Plambieg/Eketrieal Coutnetors . .
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