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Home My WebLink AboutApplication and WC _ . _ � D B ' TOWN OF YARMOUTH BOARD OF HEALTH � nrr�caTTox rox rac�xs�r�a�r=�2a� ��`�� ; DEC 1 5 2009 *Please complete form and attach all necessary da �b�tt. e tr� . Failure to do so will result in the return'o�you��r pplication p NAME OF ESTABLISHMENT: �SS 7��2 yACaT C�v,c3 TEL. # 3cr S - R 7D/ LOCATION ADDRESS:_ _�2� tl2oTi,liNG�fIA G-Aes .�dc.��O?.GL� MAILING ADDRESS: f�D . 19olt i S� , S.�. OWNER NAME: TAX ID (FEIN or SSNI: 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 Pool Operator(s) and attach a copy of the certificarion to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Communiry Cardioputmonary 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 file at yonr place of basiness. 1. 2. 3. 4. FOOD PROT�CTION IvIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time employee who is certified as a Food Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificarion tp this application. The Health Department will not use past years'records. You mnst provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 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-chokuig procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. Yon must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQLiIItED FEE PERMIT# LICENSE REQUIRED FEE PERMI7# LICENSE REQL7[RED FEE PERMIT# _B&B $55 _CABIN S55 _MOTEI, S55 � tc� � CAMP S55 �SVIINIIvIINGPOOL $80ea. _LODGE $55 _TRAII.ERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIItFD FEE PERMIT# LICENSE REQUIRED F£E PERMIT# LICENSE REQUIRED FEE PERMIT# _6�100SEATS S85 _CON7INENTAL $35 �NON-PROFIT $30 �/I ^>1005EATS 5160 _COMMONVIC. S60 �WHOLESAL� S80 RETAII,SERVICE: —RESID.KITCHEN S80 LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# LIC£NSE REQUIRED FEE PERMIT# _�SOsq.ft. 550 >25,OOOsq.ft. 5225 _VENDING-FOOD %25 ,QS,OOOsq.R $80 �� _FROZENDESSERT $40 TTOBACCO $55 xaME cxaxcE: srs AMOUNT DUE _ $ 3 0 .o0 **•••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""•" ADNIINISTRATION 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 AT�'ACHED STATE WORKER'S COMPENSATION INSURANCE . AFFIDAVIT MUST BE COMPLETED ANb SIGNED, OR' � � . . � . : : , ,. , / . ' CERT. OF INSURANGE ATTACHED V ' �`.. _ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMCNTS TRANSIENT OCCUPANG'Y: For pwposes ofthe limitations ofMotel or Hotel use,Transiern occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occuparns must have and be able to demonstrate that they maintain a prinapal placz 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 defitted 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 wlrich haue been closed for the season must be insp¢�¢� by the Health Departmentpnor to opening. Contact the Health Departmern to schedule the inspection three(3)days 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 muat be tested for pseudomonas,total coliform and standard plate coum 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 coveted within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmeat by filingthe required Temporary Food Service Application form 72 hours prior to the catered evem. These fotms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified Iab. Test results must be sent 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 Board ofHealth. OUTDOOR COOIaNG: Outdoor cooking,pre�aratio�or display of any food product by a retail or food service establishment is pro6ibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETtJRN Tf�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISF�NT, MOTEL OR POOL (i.e., PAIldTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �2^3 �6 "ri SIGNATURE: �7��/��Q�_ PRINT NAME&TITLE: 5��1.-n �.- G • /�C�,i _ � �SS.i. i r2�'A�S�2[.�1�.— 09/25/09 _ _ _ _ __ __ _ __ _ PRODUCER TH18 CEitTIFICATE IS 188UED AB A MATTER OF INFORMATION ONLYAND CONFER8 NO RIGHTB UPON THE CERTIFICATE Srtdthwk:k8 Cksrke Ins Inc HOLDER THIS CERTIFICATE UOES NOT AMEND, EXTEND OR 398 U 5 Raute One ALTER THE COVERAGE AFFORDED BY THE POLICIE8 BELOW Falmo�#h, ME 4105 COMPANIES AFFORDIN3 INSUqANCE COMPANY A GRANITE STATE INBURANCE COMPANY INSURED Bess Rprar YacM CIu6, Inc. Po Box 1 B2 South Yarmouth.MA 028B4-01B2 TNIS IS TO CERTIFY TFWT THE PWJCIES OF�URRNCE LISTE�BELOW WiVE BEEN ISSUED TO T}�INSURED NAMEU AB�VE FOR TFff POLICY PEPoOU If�IGTED.NDT WITtBTAPDING ANY REQtAREMENT.TFAM OR COI�TION OF AP1Y CANTRACT OR OTHFA DOCIAiEM WRH RESPECT T6 WHICH THIB CERfIFlCATE MIlV BE ISSUED OR MAY PERI'AIN,THE IPSURANCEAFFOROE�Tif POLICIES�SCRIBED HEFFIN IS SUBJECf TO ALLTHE TERM3,FJ�LU8101�AND OONDRIONS OF SUCFi POLIGES.UNTB SHOWN MAY H4VE BEEN REDUCED BY PAID CWMB. w �rn rnearrenuwa �auo�wu� rc�rerremNeo,�a e�auorr�w��o�ie A OENPLOVEIiB'LNBILT' uNl� E PROPRETOp/ MTNERBIEJfECUTNE FFICERB ME: wnoocc�o 5093021 7/01I2009 7ID1/�10 �T�T�nrrrs en �arew�vWr�o w opwW aM wy. �CCpENi S 100, mEwsevrn.icrtrR 5 lf�, qerwr� S 1� DESCPoPTIDN OF OPEpA710t�fV911CL�18 I�L R018 c�rtnF�cnre t��o�t avice��anoN �OFY/��UT}'� SIIOUIUANYOFTXEA80VEDE8CRBmPOLICIE68ECANCElLE�BEf6RETXE E7ffMTI0X DATE THEREOF,11fE 188UNG WNPlW'1YVILL FNDFAYOR TO IML�p 1148 RT 28 wvswnrtiex Norr.�ro n��c�riFrc��Notoex iuwm ro n+e��'e,eur SOUhiYARAAOUTti.hAN02804 FARLIIETDWILBUCMNOTICEeXALLII�O8EN00BLIGnTIONWILNeIL17'/� ANYKND UPON TXE COMPIWY,fB AGENTS OR IfEPREBENTATNE6. 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