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Home My WebLink AboutApplication and WCr " �_ 8.2. �2zs! TOWN OF YARMOUTH BOARD OF HEALTH ,, �� < �� APPLICATION FOR LICENSE/PERNIIT - ?�2 �,' � � � * Please complete form and attach all necessary d4C�n , }±�d�ecemb r I5NEV11��f� Failure to do so will result in the return of yo�r ap tcauon pac t. HEALTH DEPT. ESTABLISHMENT NAME: • � LOCATION ADDRESS: TEL.#: 3 MAILING ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pnal9gerato�(,s�and-attach a copy of tt�e certifirstian;o thisfo*ri. L 2. Pool operators must list a minimuxn 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 of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a�le at your place of business. I. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establistunents 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 this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. i. �ar � . 1 �tit`�.�ta b � 2. PERSQN IN CHARGE: _ -- __ _ _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. �. ��\1 . `�,� „� J2-.. 2. �� HEIMI.ICH CERTIFICATIONS: 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 uained in anti-choking procedures 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 file at your place of business. 1.(�aJaV� \�l.�nn�,.�, �� . 2. 3. 4. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODG7NG: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# _B&B $SS _CABIN $55 MOTEL $55 _INN $55 _C.4.4�P �55 _SWIMII4�GPOOI� $SOer.. _LODGE $55 _'IRAILERPARK $]OS _WfIIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 ��a -Q�O _WNTINENTAL $35 _NON-PROFIT $30 _>]00SEATS $160 1COMMONVIC. $60 �a�O(Q _WHOLESALE $80 RETAIL SERVICE: —RESID.K11'CHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. �80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOIJNT DUE _ $ I�S•OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM#**** �l�Y ' ADMINISTRATION � Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth 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 ta�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGYNG ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be lnnited 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 maintain a principal place of residence 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 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 Department to schedule the inspection three(3)days prior to opening.PLEASE NOTE:People are NOT allowed to sit m the pool azea 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 three (3) days prior to opening, and quar[erly thereafter. 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 DeparUnent 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 Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hoizrs prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified 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 seatingwith waiter/waitress service),must haveprior app_r_oval from the Board of Health._ 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 RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S) BY DECEMBER 15, 2011. 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 HE TH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU E N. DATE:� /Y�� SIGNATURE: � / PRINT NAME &TTI'LE: ' Rev.10/25/11 � '�'�'� � �\ . The Comraonwea/th ofMassachusetts Departineet ojlndustrialAcciJenu N�C1Nrw�tlws 600 Woshington Street, �"'F/oar Bostan.Moss. 02111, _ Worlcers'Compeoeatios Imaraaee-Aftidavih�. . � . .._ �` . ; .� . ._. , ;:"� � ,�:,�.. " � . name' �� \�'� ��.C'�.,.. - addn.ss��1_-- C--YJ_____—.—.—___— �.. � � - ci statr. — zi : � 7�� / work sih location lfutl addressl: �Z�� ❑ I am a homoowner perfoiming all wmk myself. ❑ I am a sole proprietor and have no one working in any capacity. �an employer providing workers compensation fa my anployees wodcing on this job. - -comour rne• � �.x�'(�-� �'�-�- . . d�s• d : w-� N�'�/ k: y�� 1 ft ❑ I am a sole proprie[or,geaersl eo�trxtor,or wner(cirde oueJ and have himd t6e conlracWes listed below who�have the following worlcers compensatioo polices: � �mv uoe: ad�aa• eth• oAoee N• iesea�ee ca nWkv M e000uv me- ad�• chf- . . . o�a.eih ._ ..__ . .. ____ __. .. _ _ .. ____ _... . _ _. __ . _.__ _ _ . . . _ . . . _... _ . fAsm�ceew �� . . _ � oaliev M w�r.r.+a�ra r.r r.s..f EaBve Y xeve ewaade a nq�N��dv SMY�iSA dMGL 13Z m led b tle up�NM Naf�Yd pdMe�t�9�s�p b fI,.SM.M�Ml�r s�e yen'Isprbw�ent a wd n dN penitln h tse tar�e(a STOt WORK ORDER ud�me NS3M.N�dq aplmt re. 1 odenh�d UN• capy HU6 Nahueot dy be firwardrd b Mt O�.e atlaveWplMes et tlu DIA hr teven`e ver�ntlw !!o Nrreby certlfj w anf pau/Nv o rjrry tb�NYe fwfonwrNon prodJed a8ovr b�rce awd curmR / Sigoatum . Date �� / // Print oame ' . �� Phone k � e16eV1 ex eoly M eM wrke h lhb arr�W Ee ro�PklM bY cNY ar bws��il �� . . . . � . cHy er tewo: � � permiHtleea:A QBuidlea Deparimeal � ❑e6e�!Himse6�le reapeme 6 reqd`ed . ❑'��`�� . . QSdeetuee•s OIBm ❑He+MY Depr�l msfact pensa: Py��p� �Q l .ma s�'mm�