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Home My WebLink AboutApplication and WC .-� _ �. i3�ot��ccs ' TOWN OF YARMOUTH BOARD OF HEALTH ` * • AP'PLICATION FOR LICENSE/PERMIT-2010 �.,,,�i f�/2 �`'d .{� i , Please cogiplete forn►and attach all necessary documents.Gy Decemlier I S 200 . Fai�ure to do so will result in the retum of your applicat�on pac et. , , i � _ _.�,_'. NAME OF ESTA$LISHMENT: �.� (�GPc�.. TEL. # �7Y�,�.S C.�6/7 LOCATION ADDRESS: q,;. MAILINGADDRESS: 3 No,,,� �c-. 1.�. yArr+ ..�,.A a 'Z673 OWNERNAMB: �'�C�,&,n TAX ID (FEIN or SSNI: CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: '� ? TEL. # ��Yd MAILING ADDRESS:_ _ � �/pr.mcr� �_ �. � oZ G�_3 POOL CERTIFICATIONS: The pooi sqpervisor must be certitied as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certificarion to dvs form. L 2. Pool operators must list a mmimum of two employees currently certified in basic water safety,standard First Aid and Commwrity Cardiopulmonary Resuscitation(CPR}. Please list these employees below and attach copies of employee certifications to tlris form. The Health Department will not use past years' records. You must provide new copies and maintafn a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - 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 Establislunents, 105 CMR 590.000. Please attach copies of certification to this applicarion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: — -- - - - - __. Each food establishment must haue at least one Person In Charge(PIC)on site during hours of operafion. 1. �i�� C�LSrJ 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee uained in the Heiznlich Maneuver on the premises at all times. Please list your enployees trained in anri-choking 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 Gle at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMfT# LICENS&REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 �CAMP S55 �SWIMbIlNGPOOL S80ea. _LODGE $55 _TRAILERPARK $]OS _WIIIRI,POOL $SOea. FOOD SERVICE: LICENSE REQUIltED FEE PERMIT# LICENSE REQtJIRED FEE PERMTT'# UCENSE REQUIRED FEE PERMI'f N �0.100SEA7S $85 O� �i _CONTINENTAL 835 TNON-PROFIT S30 _>IOOSEATS $160 �COMMONVIC. S60 O�b� _WHOLESALB S80 RETAII,SERVICE: —RESID.Kt2CHEN S80 LICENSfi REQUIRED FEE PERMPI'# LICENSE REQUlltED FEE PERMIT# LICENSE REQUIRED FEE PERMIT ti �a50sq.8. $50 >25,OOOsq.ft. $225 _VENDING-FOOD 325 _<25,000 sq.ft. S80 _FROZEN DESSERT $40 TTOBACCO $55 Nn�cxnivcE: sis AMOUNT DUE = S 1�l-S .o0 '•""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"""•• ADI4IINISTRATION Under Chapter 152, Section 25C, Sabsection 6,the Town ofYarmouth 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 Compensauon Insurance. THE ATTACHED STATE WORKER'S COMPEN5ATIQN INSU1tANCE , i AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR I 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: I YES_� NO MOTELS AND OTHER LODGING ESTABLISffiVII:NTS TI2ANSIEN'1'OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiern occupancy shall be � limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use. , Transient occupants must have and be able to demonstrate that they maintain a principal place ofrevd�ce elsewhere. � Transient occupancy shall generally refer to corninuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) daya within any six(6)raonth 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 wlrich have been closed for the season must be ins by the Health Departmentpnor to opening. Contact the Health Departmem to schedule the inspection thrce(� pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool atea until the pool has b�n inspeeted and opened. POOL WATER TESTING: 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 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 caters within the Town ofYarmouth must norify the Yarmouth Health I�parUneat by Sling the required Temporazy Food Seivice Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified Iab. Test resuhs must be sent to the Health Department. Failure to do so will result in the suspension or revocadon 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 fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking,prepaxatioq or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. TT IS YOUR RESPONSiBILITY TO RETURN TF�COMPLETED RENEWAL APPLICATION(S)AND REQLTIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTF.L OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF1E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SI'T'E PLAN. DATE: 1 I� SIGNATURE: ��'�1� PRINT NAME&TITLE: �`c�� CJ�N Own�2 0925109 I' W � The Commonwealth of Massachuselts DePartment ojlnduslrial Accidents �N� 600 Washingtoa Street, 7`"Floor ' Baston,Masc. 011ll ' Worlcers'Compeesatiou ies�a�ce Atlidavih Bui�diog/p�umbieg/I,rketrMy�Coatraetors Aoolleul�azmaKwl: Ptease PR_�1'k�� i� '� U� �: �� i �: '3 `��.,. �r i �;��}}axr� �n� �.� �o� o'2G7� �a 7�Y a3 G ob�� wu�ksitetocaflonlG�uada�essr. - . . i ❑ I am a homeowcer perFo�ming all wock myself. ProjectType: ❑New ConstnK;ti�QRanadei i ❑ i arn a sole�proprie[or aod have no one wodciog in any�capacity. ❑Building Addition� . I ❑ I am an�ployer providiog wockas'compensation fa my employces wodcing an this job. � �- --- -- -. .._. . ' =--� - � ::._ . . , . _ � . cum - � �ame: �`_� . - - ---- � ad�eas• ' �i N1d.ns.�� . �](� .. � . . � - . , �: �a�m� M� acc�3 � w �Y�se v6i � Ia. oe. N6-M ��t$�na�u. o. 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