HomeMy WebLinkAboutApplication and WC " TOWN OF YARMOiTTH BOARD OF HEALTH G3 0 �
APPLICAITON FOR IdCENSE/P 2010 NOV 1 6 l�09
* Please complete form and attach all neces r�$ � ec ' Utr� .
F a i lure to do so w i ll re s u lt in the retu�a yo "�icataon pac .
NAME OF ESTABLISHMENT: ` �SS 2`�`L�� ��J �` L'�v-a L'�U TEL. # S�-3�1 `��,
LOCATION ADDRESS: T �
MAILING ADDRESS: C 2ri� ����c2; rn 4�. a�l� �
OWNER NAME: or S •
CORPORATION NAM�E�IF APPLICABLE): 1 �� Q. �L-7�n� � i..l C_
MANAGER'S NAME: 1—t Q:- �r-� , TEL. # S�'3 31�.'l -r3'CFi�
MAILING ADDRESS: -o._t, � � M
POOL CERTIFICATIONS:
The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attac�a copy of the certification to this form.
1. � � � - 2.
Pool operators must list a minimum of two employees currendy certified in basic water safety,standard First Aid and
Comcnunity Cardiapulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee
certificarions to tlus form. The Health Department will not use past years' records. You must provide new
copies and maintain a fde at your place of business.
1. 2.
3. 4.
FOOD PROTECTION IviANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past years'records.
You mast provide new copies and maintain a file at your establishment.
1. �� (��l �-�Q�b� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
i. �'�lA��� Q.�O� 2.
HEIMLICH 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 trained in anti-choking procedures below and
attach copies of employee certificarions to this form. The Health Department will not use past years' records.
You must.provide new copies and maintain a t'ile at your place of business.
1. ���--���.2�� 2.
3: 4•
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL S55
� INN $55 CAMP S55 �SWA4R�IING POOL S80ea. .
_LODGE S55 uTRA1LERPARK $105 _WHIRLPOOL $SOea.
FOOD SERVICE:
LICENS$REQUIILED FEE PERMIT# LICENSE REQUQtED F�E PERMII'# LICENSE REQUQZED FEE PERMI'I#
0-100 SEATS S85 _CONTINENTAL $35 �NON-PROFIT $30 #1'�0-0[�/
� _>100 SEATS 5160 _COMMON VIC. $60 _WHOLESALE $80
RETAII.SERVICE: —RESID.KITCHEN S80
T.ICENSE REQUIRED FEE PERMIT# LICENSE REQUlltED FEE P£RMIT# LIC£NSE REQUIItED FEE PERM[T#
�' <50 ft. S50 >25,OOOsq.ft. 5225 _VENDING-FOOD S25
—. s9� —
I _QS,OOOsq.ft: � � �. $80 � . � � � �� �_FROZENDESSERT 540� . TTOBACCO S55
� NAMEC}IANGE: $15 � AMOUNTDUE _ $ 30.00
i
� ••""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"•'"*
� ,, ADMINISTRATION : _ �
Under Chapter 13,�,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 COMI'ENSATTON 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 permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS -
TRAN5IENT OCCITPANCI': For purposes ofthe limitations ofMotel or Hotel use,Transieut occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customazily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal plac:e 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 whiripools wtrich have been closed for the season must be' p
by the Health Departmetrt�pnor to opening. Contact the Health Departmem to schedule the inspectiomthree(3)d�ays
pnor to opening.PLEASE NOTE: People are NOT allowed to sit m the pool area umil the pool has baen inspected
and opened.
POOL WATER TEST'ING: The water must be tested for pseudomonas,total coliform and staadard plate count
by a State certified lab, and submitted to the Health Depariment three (3) days prior to opening, and quarterly
_ thereafter.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaitment by the required
Temporary Food Service Application form 72 hours prior to the catered evem. These forms can be o ' ed at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sem to the Health
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Perndt until We
above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOHING:
Outd_oor cooking,pr�aratio�or display_of any food�roduct by a retail or fo_od service establishment is pro6ibited. '
NOTICE:Permits run annually from January 1 to D�ember 31. IT IS YOUR RESPONSIBII.ITY TO RETURN
TI� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(Sj BY DECEMBER 15, 2009,
ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR '
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. :
DATE: � � t �' � Cl� SIGNATURE: ,
PRINT NAME&TITLE:�?��2� �� , ti
0925/09
" ' �'\ The Commonwealth ofMassachusetts
Department of Indushial Accidents
N�fCIN�
600 Washington Sdee[, 7`"Floar
Boston,Mass. 02111
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