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Home My WebLink AboutApplication and WCi � � � � $l..o�1Dl�S .�. � ^� �� TOWN OF YARMOUTH BOARD OF HEALTH �.,�-� _ � APPLICATION FOR LICENSE/PERMIT�20 1' : r � , . � FEB 2� 2011 � * Please complete form and attach all necessary documents y Dece �er IS 2010. , F a i lure to do so wi ll res u lt in t he retum o f your application pa et!-i�:N€.:i l � '��.�?f ,. = _. �._.` ESTABLISHMENT NAME: �ct�i�S 1CQCreq.n TAX ID: �� LOCATION ADDRESS: TEL #: ��Sr-238-C�/Z MAILING ADDRESS: 3 yMMA N�� j2. �-•+• M� oz6'i� OWNERNAME: �k� V��' � CORPORATION NAME (ff APPLICABLE): --�(,�qk,�,tt S MANAGER'S NAME: ioa� C�S,rJ TEL.#: MAILING ADDRESS: Su�� 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 certification to tlils form. 1 2. Pool operators must list a minimum oftwo employees cunently certified in basic water safety,staudard Fust Aid a�id Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications 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. I. Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments az•e required to have at least one full-time employee �vho is certified as a Food Protection Manaeer, as defined in the State Sanitary Code for Food Seivice 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. ��SF�nG �h[h'�h� 2. PERSON IN CHARGE: � Eacn food estabGsIunent must have at least one Persoii In Charge (PIC)on site durnig hours of operation. 1. a Z c� �7 ��in 2. HEIMLICH CERTffICATIONS: 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 u•ained in anti-chokuig procedures below and attach copies of employee certificatious to this forni. The Health Department will not use past years' records. You must provide ne�v copies and maintain a file at y�our place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PE&'bIIT= LICENSE REQUIRED FEE PE&\4I7= LICENSE REQUIItED FEE PER'�IIT g _B&B S55 _CABIN S55 il�OI'EL S55 —� �S� _CAi1�IP S�5 _S!t'I1�'11INGPOOL SEO::.. -� _LODGE S55 �IRAII,ERPARK 5105 �\VHIRLpOOL S80ea. FOOD SER�'ICE: LICENSE REQIDRED FEE PERMII'# LICENSE REQUIRED FEE PER\�Iff= LICENSE REQUIRED FEE PER�SIT r �0-100 SEAI'S 585 � I�I�O� _CONIIIVENTAL S35 NON-PROFIT S30 _>100 SEA'IS 5160 � �COlVA40N�'IC. S60 ��g _R'HOLESALE S80 REI'NL SER�'ICE: —RESID.KI7CHEN SSO LICENSE REQUIRED FEE PERbIII'� LICENSE REQUIRED FEE PER'�II7# LICENSE REQUIRED FEE PERbIII'# _60 sq.8. S50 _>25,000 sq.ft. 5225 VENDING-FOOD S25 _<25,OOOsq.fc S80 _FROZENDESSER"I540 "IOBACCO Si5 �a�c��cE: sis AMOUNT DUE _ $ 14 5.00 *""*"PLEASE TtiR\OVER A\D CO3iPLE'IE OTHER SIDE OF FOR�I"*•** � . ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth 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. 1'HE ATTACHED STATE WORKER'S COMPENSATTON INSURANCE i 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 pernuts. PLEASE CHECK ' APPROPRIATELY IF PAID: YES � NO - ]y[OTELS Al!'B L�T73EB 1�.Q�GLN�E�TA�I,IS�IlYZE1�TS TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be ! limited to the temporazy and short term occupancy, ordinarily and customarily associated with motei 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 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 Transient. ' POOLS ' POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Depariment prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening. PLEASE NOTE: People aze NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WA1'ER TESTING: The water must be tested for pseudomonas,total wliform and standazd plate count 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 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 DepaRment to schedule the inspechon three(3) days prior to opening. CATERING POLICI'• ' Anyone who caters within the Town of Yarmouth must norify the Yarmouth Health Departme�rt by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's 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 Aealth 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 approyal from Ihe Board of�Iealth. i, OUTDOOR COOHING: Outdoor cooking,preparation, 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 RESPONSIBIIITY TO RET[JRN ' THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW , EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: 2 2 /� SIGNA E: � ' PRINT NAME&TITLE: ^�C� �Jne� io�oe��o Y � �\ The Commonwealth ofMassachusetts j • Deparhneat ojlndes[ria/Accidents i N�eiN� � 600 Washington Street, Y"Floor Boston,Mass, 011ll � Workera'Compeesallos Iroennee Atlid�v&; gaildiog/Pl�mbieg/Ekctrical Co�traetors . . �tl~: � �r�'k�bl► name:`� � C� n addtcss: _�_.��N �— .._.--�---�---��--�--�--------�-- ��.. sm« ^,� � �zy�3 sh��Y 7�Y d-�s�c�r� .��sa�i«�;��r�u�aaa�sr �,] I am a homeowner pert'oimmg all work myself. Pro ect T ❑ [am a sole proprietor and have no one wo ln an � � Y�� ❑New Constnn;pop❑Remodel ��5 Y p��ly ❑Building Addition [�I arn an employer providing workers'compensati�for my employees working on this job. � _ . . eomo...mr. �f'tl4 ...�'"n� -`3+�� - . .. . .- - -��-- � - . . . . _ . -: ._ .. ,am�.: d q� ' i � �t : S� vz�6v �x: 7?Yr2� -06/7 � �.��. ��.a�, � 5��6�t�� .. 3�57 r�yU � ❑ [arn a sole proprietor,ge�eral co�tractor,or hommwwer(circ(e ouel�d have hired tl�e contracto�s listed below who have the following workers'compettgation pofices: �' mmmov me- addresa• �� o`ose R ieeeasee ee. � �lv me• adi'efr eih: oYa�slf- _ .._____. �_- _ -__ ___—__ .—___ ._ - . _ . _. .__-_. _.___ -__ ._. __ ._.___ _ ._—_ ___.- _ _. . . . . _____.... fY nr�rwrr.r,rrr.....r '� F�Bve 0�xcve eo�erKe u`eqdred��dv S�2SA d MGL I33 u�kad O tYe��r . . � . 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