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Home My WebLink AboutApplications, WC and Licenses Prior to 2010_..�--�- , i, ,�",, �; TOWN OF YARMOUTH BOARD ��,0 w � 5 �L i� M �c � �� APPLICATIONFORLICE A i O��nf� N�,';/ j 4 ZU08 * Please complete form and attach all necep d�ments by Dece 'DEPT. Failure to do so will result in the ret�of yow applicahon pa . ' NAME OF ESTABLISHMENT: �i.qsr ��rn �.qcs�.— �Gv� TEL. # 3S�- �i'7o / LOCATIONADDRESS: ?� n A 5• Fl�t�+ov i MAILING ADDRESS: /'30 X /S� S. �i�Janrnoc,d , O��L OWNER NAME: TAX ID (FEIN or SSNI: CORFORATION 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 certification to this form. 1. 2. Pool operators must list a minimum of two employees cun•ently certified in basic water safety, standard First Aid and Coxnxnunity Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies ofemployee 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. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 maintaiu a file at your establishment. 1. 2. PERSON IN CHARGE: _ . Each food establislunent must have at least one Person In Chaz•ge (PIC) on site during hows of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures 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 file at your place of business. 1. Z• 3_ 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGIV G: LICENSE REQUIRED FbE PERMI'I# LICENSE REQUIItED FEE PERNIIT# LICENSE REQUIItED FEE PERMI'I n B&B S55 _CABIN �55 _MOTEL S55 INN S55 _CAMP �55 _SWIIvIIvIINGPOOL SSOea. LODGE S55 _TRAILERPARK �105 _WF3[RLPOOL 580ea. FOOD SERVICE: LICENSE REQIJ[RED FEE PERMIT# LICENSE REQUIR�D FEE PERMtT# LICINS&REQi7IItED FEE PERMI'I# 0.100 SEAZS S85 _CONIINEIVTAL 535 LNON-PROFIT S30 � >100 SEATS 5160 _COMMON VIC. S60 _WHOLESALE S80 REiAIL SERVICE: —RESID.KITCHEN SSO LICENSE REQUIRED FEE PERMIT f? LICENSE REQUIRED FEE PERNIIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.B. 550 _>25,OOOsq.ft. S225 _VENDING-FOOD S25 I�� _<25,000 sq.ft. S80 _FROZEN DESSERT 540 - _70BACC0 S�5 ��zE cxn�cE: sio AMOUNT DUE _ $ 30 .no . **"•*pLEASE TUR\OVER AND COMPLE'IE OTHER SIDE OF FOIL'1-I'""** r N • Z ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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 Compensarion Insurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED �c�� 8 -oo - yr Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pemvts. PLEASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND O"f'HER LODGING ESTABLISHMENTS TRANSIENT OCCITPANCI': For purposes ofthe limitauons of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customa.rily associated with motel and hotel use. Transiern occupants must have and be abie to demonstrate that they maintain a principal piace 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 ins ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days pnor to opemng. PLEASE NOTE:People aze NOT allowed to stt m the pool area until the pooi 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, 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 CATERING POLICY: Anyone who caxers within the Town of Yaimouth must norify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health DeparUnent. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test resuhs must be sent to the Health Departmem. 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 COOHING: Outdoor cooking,prepararion,or display of any food product by a retail or food service establishmem is prohibited. N01TCE:Pernrits run annually from Januazy 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQLTIRED FEE(S)BY DECEMBER 15, 2008. 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 HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �I- i 3 -D$� SIGNATURE: ��)n.....� �. ��,- ., PRINT NAME&TITLE: Ss��.�2rnq.✓ G- f�Rl��„i„/ /a SST. J�7G A s�-�Z�yZ �o.�zi�os �,�_� , . � �\ The Commonwealth ofMasswchusetts Departinent of Indwstria!Accidentc N�eINi��Ms 600 R'ashington SYreet, 7`�F(oor Boston,Mass. 011ll Workera'Compe�sadoa iaam�asce A�davk:B�ildiogiPlambieg/Ekctrieil Contractors 1�S iWe�Us�: P'irse PRINIT 1eA�ir �: ��nss %2��- `/.nc.�r CL�, �s: �a. �� x �sz. �b � 7A6C MD L j}/ state• �19 • � � zin• G•Z�e�i� ohone# � %��'/ 7V` 1 . wock site locati�(full addressl: �� . . ❑ I am a hom�w�r perfoiming all w�k myself. Praject Type: ❑New Constructi�❑R�odel ❑ I�a sole�proprietor aod 6ave no otie wotking in mry�cap�ity. ❑Building Addition � ❑ I am an�ployer providing walcers'compensation for my employees wodcing am this job. . �- com�v�e• � � _ . .. _ . . . ... . . . � .� . . ad�as: . . . � � . . . . . . dtr' oYme N' � � . ea M/%}{L�/CK r R/Z//vb'yR r e l/V C 2'f8'C�Q" y - �.. � � � � -� .. -..�.�>�� ...s..:w ❑ I am a sole proprietor,ge�eral ewtractor,or�omeawwer(cirde owe)and have hired the contiactas listod below who have � tl�e followiog walcas'compensaGon polices: . . t�mmov�ant• � �� . . . . ad_dN[��: . � . . . � . . . �" . .. � . . �� o�aek: � . . . . . . � . . i�eva�ceca. . . . natle�# � � . - . . -. ,_ _ ., . . . . . r . .. . . .,r,. . .��:= t't,�-^;"a aanort imr �' e�t fe. . � . . . . . oYa�eN- . . � . � -- — -_ _— _- —�-- - --- -- . ___ __- . . �� _-- _. . ... . . . . ... .— . . .. ,�-. - �, x 4'�^z „.�«r�: Failve b+eene cavnage n nqd'M odv 9ecWa 2SA�f MC.L LS2 en IW b IYe�W daidW peWlin�fa�at�N S7.3MM aWl�r �ee ynn'ImprWa�eet a�wd n dN pmMin 61Ye tor�Na STOt WORK ORDER atl�9ee dSiM.N a My gYnt se. I mdnahsd t6�t a dpy�[Hhthlewlmyhef�ward�MNeOmceotla�afWeDlAfrawmgevvqlnMe. - �lo berey cerfffy,u�° d1e paGu.ur�of"'`�'y tbu dYe infana�lon Pnovlaet abore fs we�Aoenecc� � . . s;�tt Z"7•�-.. �• ✓J�•Pc.�� —.— n,u /�- � 3- a8" p�� 5..��,�A,� L. v�l��..�1 rn�Mu 9�'- � effxid.uwry eo■a.rrkeYtm.■rcaweemoplefedEreHr.rw..�.md.� . . .. dlyertawe: �. . ,.�d p�� ❑tYadifisma�Ee'espome6ttqmred � . . �Stlec�a90�ae . .. �HnNY Il�t n�fR Pawe: P�xe d; ❑Olbe+ lmieaSWtmm) . r , � { TOWN OF YARMOUTH BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NUMBER: #09-012 FEE: S30.00 i In accordance wi[h regula[ions promulgated under au[hority of Chapter 94,Section 305A and Chapter l 1 t,Section 5 of the General Laws,a permit is hereby eranted[o: Bass River Yacht Club, 22 Frothingham Way, South Yarmouth, MA � Whose place of business is: Bass River Yacht Club Type of business: Non-Profit Food Service To operate a food establishment in: Town of Yarmouth ' Permit expires: December 31. 2009 BOARD oF HEALTH: �feeert S�taPi, �J2..N, C,l(tai�[nuae CR�a�ea .�. 9CePLiR�. `Uice @hsuxr►cauc J`Zo�e,it �. 5ixown, C�enPi Q�:ec !�'xeen6acure, ✓2.✓Y. �n�- �� i � Nocember14.2008 ce G:Murphy, .5., CHO Director of Health I ; ' � �. lL. yA c E}T Cc,clB j r � YRj� TOWN OF YARMOUTH BOARD OF HEALTH �"`'�'�, � ��y=$ APPLICATION FOR LICENSE/PERMIT-2Q� �� { �'';' �. ,�� Z007 * Please complete form and attach all necessary docume�s b�i� er 31, 2007. Failure to do so will result in the return of your appli� n packet. � NAME OF ESTABLISHMENT: OaS3 .C.rc�2 �►cs/T CCr.a TEL. # 39 FI -�'i70/ LOCATIONADDRESS: �Z2 frlo7Hi,v � ,�.� q S. �r��.rv, uo MAILINGADDRESS: /3oX /8� S. Az,n-,u�. 0.2G OWNER NAME: _ TAX ID fF IN or Nl� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # ; MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certiTied as a Pooi Operator,as required by State law. Please list the designated iPool Operator(s) and attach a copy of the certification to tlus form. L 2. Pool operators must list a minimum of two 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 certiScarions to tlris form. T6e Health Department wilI not use past years' records. You must provide new• copies and maintain a file at your place of business. I. 2: 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are requ'ved to have at least one full-tune employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. 'i'he Health Department witl not nse paat years'records. You must provide new copies and maintain a Tle at your establishment. l. 2. PER�9NZNC�3AAGE: - -- _ _ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. I. 2. HEIMLICH CERTIFICATIONS: All food service estab6slunents with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and iattach 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. 2. 3. 4. RESTAURANT SEATING: TOTAL # , OFFICE USE ONLY i LqDGING: I LICENSE REQUIRED FEE PERbfI"I# LICENSE REQL'DtED FEE PER4IIT 4 LICENSE REQUIRED FEE PER'�ili= � _S8c8 S50 _CABIN S50 _MOTEL � S50 _iNN � 550 _CA.1IP S50 _SWIVLbfING POOL S75ea. _LOD('iE S50 _TRAILERPARK 5100 _«'I-IIRLPOOL S75ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT r� L}CENSE REQUIRED FEE P£R4IIT= LICENSE REQti IRED FEE PER�fIT= �� _0.100 SEATS S75 _CON'IINENTAL S30 I NON-PROFI7' S2i �� _>100SEATS 5150 _CO:bL�SONVIC. 550 K'HOLESALE S7i �� RETAIL SERVICE: —RESID.KITCHEN S75 � LICENSEREQUlRED FEE PERMIT= UCENSEREQUIRED FEE PER�9T= LICENSEREQtiIRED FEE PER�IIT= _a50sq.ft. S45 _>35,OOOsq.ft. S?00 VEA'DING-FOOD S20 _QS,OOOsq.ft. S75 , _FROZENDESSERT 53i TOBACCO S50 vn:�cxa.�vcE: sio AMOiJ1�T DUE _ $ aS,0 0 •"*"*PLEASE 7L'R\O\'ER 2��CO�iPLE7'E O7"f�R S[DE OF FOR�S'""r* ,. , ' r 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 � wC ��S-oa -y/ Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your pemuts. PI.EASE CHECK APPROPRIATELY IF PAID: YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCC[TPANCY: For purposes of the limitations of Motel or Hotel use,Transient ocwpancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must haue and be able to demonstrate that they maintain a principal place ofresidence elsewhere. Transiern 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 sha11 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 TransieM. * NOTE: En��o�d Moted Census must be completed and returned wrtb r�s aPpuoat�on. rooi.s POOL OPENING: All swimming,wading and w(vrlpools which have been closed for the sea.son must be' ected by the Health Department prior to opening. Contact the Health Department to schedule the inspection five(�days pnor to opening. POOL WATER'TESTING: The water must be tested for pseudomonas,total coliform and standard 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 CATERING POLICY: Anyone w6o caters within the Town of Yarmouth must notify the Yazmouth Health Departrnent by fiting the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health DepartmenY. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspens�on or revocation of your Frozen Dessert Permit urnil 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 ofHealkh. OUTDOOR COOKING: _ atio�,e�ctispFay ef any food pre�eeE by a retail or food service esta�listunent isrprohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. I1'IS YOUR RESPONSIBII.TTY TO RETURN TI-IE COMPLETED APPLICATION(S)AND REQUIltED FEE(S)BY DECEMBER 31, 2007. ALL RENOVATIONS TO ANY FOOD ESTABLISFIIv1EEIVT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR TO COMME_VCEME�IT. REVOVATIOVS MAY REQUIRE A SITE PLAN. � DATE: SIGNATURE: ��- � ��a w, PRINT:vAN1E&TITLE: � SST. Trt�,q S'v2C2 io;n u� ' , �''\ The Co�monweakh ofMassachusetts Departmeat of Indusirial Accidents Nf�'IN� 600 R'oshington Stree; 7'"F[oor Boston,Mass. 02111 Woricera'Compe�eatio�I�soraaee ASdavk:B�Idiag/Pl�mbi�/Eketirical Co�traetors ��. ♦.wil.y.r i�t..�11..• Pl�ue PIt1[iT I�Yh name� �/1 SS /<i vE/l �F+CEfi �L�'j3 ' address� � b . �Ox /Sr'Z �+�^ �^ ��/A��ZMO!/�'� a�ce� /�'!!.Q zip- �e�d�. � nhme# /Q&' �70 "n! 7�� . work site Iceation(fvll ad�essY ❑ I am a homeowcer petfocming a11 woik myself. Project Type: ❑New Caostruc.Kim ORemodel ❑ I am a sole proprietpr and have no one woiking in mry capacity. ❑Bwlding A�ition ❑ I am an employer�ovidi�w«ke[s'wmpensatiw f�my�ployees wodcing a�this job. � ._ . _----- --.�__ ..._ ---.__ ,_. ...-- .._ . .� -��-- ._ __ - . _. . . . _- -------- _. ----�- -.._. . . . _._ ._ . co noe• . �s• dry• d�e#- . i...er.e�e9. S/7T'IL../CK r �AIZ/NG�CS p�,y@ G�� c �I��'OO �I -- w;�3,.��, ..�, ❑ I am a sole proprietor,ge�ersl ca�trxMr,ot Yomeow�er(cale�owt)aed have hiced/Le contructocs lisled below wla have the following walcecs'compemcation polices: addreas• dn• o�N: i�ri.M ca. poljey M add�eN• �y � oYa�e M: - - -- -- -- — — ----.. _.__. _ M �-��Y. . � : . . . �� .. .. . :� .. FaYveYxcRa�eneeoteqdradodeSedir�A�MC.L13tmkWbtYe�ilMdalidpmMb�fa�e,rbSl.M-M�Wr � eee ynn'IepMessrmt af wd u dvi penNb Is tie 6r�da 310r WORIC 0811SR ud�8u KS1M.N a dty apimt� 1 odenh�d HN• e�py dUb Aaie�el my he finvadeA 6e the O�re afLvntlpWd KUe DIA tar asvea6e ver�e�tlN. /do 6en6q csr6fy rnlsr Me pLu a�d ptnalL�nlD��pr/Y Ma Me tefennrlon provlda/e6nre 6 ave aud cermc Sig�utu¢ ��- �• ��CJC G.�� Dste // -/(•-�7 Printname S/�-%2/�'�f7�J L. �ALI�(�/�'✓ Phone# .7�0 ' '�� -�e�� .�ehl..e o.y ao o«.Mfe r tYi..re.N ee wWefN Dr eNr.r r�m.mefd I�I ci�or tswu: p�� BaaN I ❑e6edc NI�udL1e rtapeme h rcqui'ed . ❑3dec�n'f O�ce � ❑II�Dq�at nahc[peneu: p��: � 1n�isd Syt mol) i iTOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLIS�NT PERMIT N UMBER: #08-012 FEE: $25.00 � In accordance with resulations promulgated under authority of Chapter 94,Secrion 305A and Chapter 111,Section 5 oFthe Zienerel Laws,a permit is hereby granted ta Bass River Yacht Club, 22 Frothingham Way, South Yarmouth, MA Whose place of business is: Bass River Yacht Club Type of business: Non-Profit Food Service �' To operate a food establishment in: Town of Yarmouth �' Permit expires: December 31, 2008 BOAitD oF�aLTH: .�EePx�a SR�aRr., SZ.JV., C'IFaixman (.RaxPee .�.9Cef.P1lEe�c `vice C'lEaix�na�c i Qnn.�r��m �J2.✓Y. I ' i rro��ber zo 200� Bruce G.Murphy,MP , .,CHO f Director of Health I I