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Home My WebLink AboutApplication and WC I— -- I _ -.,r--_- � � -� l o�7� ��7��= � � O��'�R " G3f� C� I� OM � L/ _ r• e �. TOWN OF YARMOUTH BOARD OF i ��s APPLICAITON FOR LICEN k¢� MAY 1 9 2006 ' � * Please complete form and attach all n � ' � ents by D �,�,��PT. Failure to do so will result in the r' ' o your appfication . � NAME OF ESTABLISffiVIENT: sr�z i �t-�.s sau sE f' F,az r c c— TEL. # 4��43 2�t1 043 y LOCATION ADDRESS: zzo �rµ sr. s. �.�(-� MAILING ADDRES S: P.o. eo x �4 3 5_ o�-xxu�s, ,r��9- 0 2�,l,�f OWNER NAME: �r A-�uu� co�-�F-ra-S TAX ID(FEIN or SSNI• CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: DI�� cou,!{-7u5 TEL. # S�' 7�F/ o43y MAII,ING ADDRESS: R o sv x fo q �i POOL CERTIFICATIONS: T6e pool supervisor roust 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. 2. Pool operators must list a minimum oftwo employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary 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 new copies and maintain a fJe 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 Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to tlus applicarion. The Healt6 Department will not use past years' records. You must provide new copies and m�intain a fde at your establishment. I l. b1A-�NE= Co�(}�Tt�S 2. PERSON IN CHARGE; Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. D�l�u� �o u.R-�-uS 2. HEIlb�ICH CERTIFICATIONS: �� All food service establishments wi 25 seats r more must have at least one employee trained in the Heimlich Maneuver on the premises at all time . ease list your employees trained in anti-choku►g procedures below and at#ae}i eopies 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 piace of business. 1. �� 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGIlVG: LICENSE REQUIItED FEE PF,RMIT N LICENSE REQUII2ED FEE PERM['P# LICIIdSE REQUIltED FEE PBRMI'1'# � _B&B S50 _CABIN $50 _MOTEL S50 I� _INN S50 _CAMP $50 _SWIIvII�9NGPOOLS75ea. �'��, _IADGE $50 _TRAII,ER PARK S50 WfIIRI,pppL $75ea I� FOOD SERVICE: . LICENSE REQUIl2ED FEE PERMiT# LICINSE REQiJIItED FEE PERMIT# LICENSE REQUIIiF,D FEE pgRl�qT q �0-100SEATS S75 �tOb_!$O CONTiNENTpL S30 _NON-PROFTT $25 _>100 SEATS $150 _COMMON VIC. $50 _WHOLESALE $75 . RBTAIL SERVICE: LICINSE R6QUII2F.D FEE PERMIT# LICENSE REQUII2ED FEE PERMIT N LICINSE REQUII2ED FEE PERMIT# � _60sq.ft. $45 _>25,OOOsq.ft. $200 VENDING-FOOD $20 ��. _QS,OOOsq.ft. E75 _FROZENDESSERT $35 _TOBACCO S25 ' NAME CHAftGE: $10 AMOITNT DUE _ $ �S °v '•""•pLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM••*•• , � _ .�.__�.:u -� - , 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 pernut to operate a business if a person or company does not have a Certificate of Worker's Compensaxion Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE ( AFFIDAVTl'MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewai or issuance ofyow permits. PLEASE CHECK APPROPRIATELY IF PAID: YES X NO NOTICE:Permits run annually from January 1 to December 31. TT IS YOUR RESPONSIBI[dTY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 31, 2005. SEASONAL ESTABLISfIMENTS ARE TO CONTACT THE HEALTH DEPARTMENT FOR INSPECTION 7- 10 DAYS PRIOR TO OPENING FOR TI� SEASON. AIJ, RENOVATIONS TO ANY FOOD ESTABLISHIv1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO C011R�IENCEMENT. RENOVATIONS MAY REQUIltE A SITE PLAN. '� ADDTTIONAL REGULATIONS i I POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspeded by the Health Department prior to opening. i POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count ' by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ' closing. ' FOOD SERVICE I CONSUMER ADVISORY: Each food establishment which serves or sells ready-to-eat,raw or undercooked animal products aze required to post Consumer Advisories. CATERING POLICY: Anyone who caters within the Town of Yarmouth 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 obtamed 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 Heafth 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 ofHeahh. OUTDOOR COOKING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishmern is prohibited. 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