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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD O �� , � �� APPLICATION FOR LICEN � '�t ` ; __� �� * Please complete form and attach all neces� do �"ent y ece b � Failure to do so will result in the ret�of your application �'. ESTABLISHMENTNAME: r � 1 r-� i `"—(<_ TAXID: LOCATIONADDRESS: % %/ �<t�,�� T<° �ls� �� atMrh�' TEL.#. �1�; ;';/�/ -,/��c-!�% MAILING ADDRESS: '' ro ` OWNERNAME: ��t,�c,.1��1 �i )�; ;Jl�oiic�y : �'�° 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 desienated Pool Operator(s) and attach a copy of the certifi�ation to this fonn. 1. 2. Pool operators must list a minnnum of t�vo employees cun•ently certified in basic water safety, standard Fn•st Aid and Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this foim. The Health Department witl not use past 3•ears' records. You must provide new copies and maintain a file at y�our place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments az•e required to have at least one full-time employee who is certified as a Food Protection Manaeer, as defined 'ui the State Savitary Code for Food Seivice Establishmeuts, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department wili not use past y�ears'records. You must provide n w copies and maintain a Gle at your establishment. v '—�—�� / � 1. / ��' ,/. 2. PERSON IN CHARGE: Each Yood estabusiunent must have,at least one Person Tn Charee (PIC) on site durine hours of operation. 1. /� /: \ i / 2. /-`�'s��Y(m/� � i!P=��'//,% :%y�/ ,. , , � .�-.� HEIMLICH CERTIFICATION . All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at ali times. Please list your employees tranied in anti-chokine procedw•es below and attach copies of employee cei7ifications to this foim. The Health Department will not use past years' records. You must pro��ide new copies and maintain a file at ,your piace of business. l�y / � . 1. ��7c�..=c��E l ' //'� ,..,�t`✓%' 2. 3. � 4. RESTAURANT SEATING: TOTAL # ,��> OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERYIII'# LICENSE REQUIRED FEE PER�III'fi LICENSE REQUIRED FEE PER'�41i# _B&B S55 CABIN S55 \40I'EL S55 �� _!NN S55 __..-----_- --CAiVIP S�i _S\'�-1VIMINGPOOL SuOea. _LODGE S�5 _TRAILERPARK 510� �\L'HIRLPOOL S30ea. FOOD SER\10E: LICENSEREQLIIRED FEE P�ELR\41T= LICENSEREQI?IRED FEE PER\�IIS= LICENSEREQUIRED FEE PERbI1T- I 0-100 SEArS S85 Z} I-�IZ _CONTINENTAL S35 NON-PROFII S30 _>100 SEATS 5160 I CO\�vION VIC. S60 � _\4I-IOLESALE S80 RE7�11L SERVICE: —RESID.KIICHEN S80 LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PER�SIT- LICENSE REQUIRED FEE PER�IIT# _<SOsq.ft. S50 _>25.00Osq.ft. S225 VENDING-FOOD S25 _<25,OOOsq.ft. S30 _FROZENDESSERT S40 I'OBACCO S» ��E c��cE: sis AMOUNT DUE _ � I�5 .� """"*PLEASE I'tiR\O�'ER A\D CO�IPLETE OI'HER SIDE OF FOR�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 petmit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STAT'E 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 taxes and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODG�T(> ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe limitations ofMotel or Hotel use, Transient cecupancy 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 demonstrate that they maintain a principal place 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 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 inspecUon three(3)days pnor to opening. PLEASE NOTE: People aze NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WA'I`ER TEST'ING: 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 quartedy 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 Department prior to opening. Please contact the Health Department to schedule the inspect�on three(3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obta�ned at the Health Department, or from the Towds website at www.yarmouth.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 seating with waiter/waitress service),must have prior approval from the Boazd ofHealth. OUTDOOR COOKING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishment is prohibited. NOTTCE:Pernuts nui annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQi�I��A SITE PLAN. - DATE: �� /�"' / ��. � �,�(/ SIGNATLJRE: �'� _ _ PRINT NAME&TITLE�' — ' � � �. ` �p ��/ � _ � � �o-o6�io ��i,=v.O/Z��✓��J��4IC%i�' � ' . �\ Ttie Commonwealtk ofMassachusetts Departraent ojlrtdustrialAccidents ' NAfe�N� 600 Washing�on Street, 7`"Floor Boston,Mass. 011l I Workera'CompensaKoe Imoranee Atfldavit; gaildiog/Plembieg/Electrical Coetraeton � � A°°Nest idrwm�tlnc Pkar PRrn1'k�bh n � � � � � name- '7/ -'.Y ;�/.� � � i-� �/��i .i: _ . `' a.� /� � � addlcss�__�._\�`� � ✓��`+Y-�-i�=1��9�___ T` __ __.— ___- .—___ 1 ,� X�[�� ci�Y_�r'd > � tY�,� sha[r �y� zio .�7 -E - �hooe# �� 7�—=�Y�=-�— work sitc location(fiil7 address): ❑ I arn a homeowner per(ormu�g all wodc myself. Pro�ec[Type: �New Construcdon QRemodel ❑ I am a sole proprie[or and have no one working tin any capacity. ❑Building Addicion � I arn an¢mployet providing wod�ers'compensa�Tor my employees wodcing on this job. comoa�v nme: � � ti r �: P'id�Y � �� }r�'7J/t� . .a�,• i -,I/ /=/17i� �—%-� � ` � ci fTvr � L7U "l/_�.13' �� 1J �:� s.;_� T�� e N- ��, � � � � J, Iuma�ee ca - _ �.,�� .-- .��'//� ❑ [am a sole proprietor.geaeral eo�trxtor,or 6omeowner(circl�one)and have hired the contractors listed below wM�have the following workers compensation polices: mmwuv�ame- addras- CI[Y: DIIM!K ieemaeee ee. � wmouv ad• . . adaar c�• oia�e N Itiva�ee ca oaLiev Y � __. . . . . . emw�rrr+.rr..e..rY Fa�ve d srtme�erade n rtqehM�tiv Sectlo�ZSA af MGL 13l eu Ind b Ue I�pr�do�ld . . . . . ^�e Ynn'leprhw�wt n wd as dH pea�itla 1�t6c fer�ef a 3TOl WORK ORDER aW�Dee af S1Bl.O��+d��f��ne R b f1.3MM aW/�r eepy a w..�,e.em o.y ns rerw..�deA e.roe oeke.r�aveal�u.n or 16e nu ra c�ve�e.2Nee,u... �r�W�•�:. �sede,sa.a uu. !b hereby ce / ��drr �JY �AE palns ud penrhlv olperJury GYd Mr lwfor�nmion provJdN eboue Lf�rue iwd rormt s��„R _ A v � '`� n,rc ,L�/—�/cJ � ' �-,� � � / s Print� :D - .�- � ��a<�� C�i � �'-�' �-'ir,y PhoneS ��Js.. c ef�id ox¢aty_ �� do ne1 wrMe h�1hN�rn fa 6e rn�p1e1M 6y c11y or e�wo aBkW . � . Nty or tawn: IK��'�me C QBaldloe Dtpvdeet ❑eheek HimmeM�ee reepeox 6 rcqdred �IJces�lae Be�rd QSdecfuea•s<Mece rnefM penoo: phwe N: �HeaNY D�ar�a[ f�..me sq.mm� �e