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Home My WebLink AboutApplication and WC �, BASS Q!✓g?ZL�D(+� a � TOWN OF YARMOUTH BOARD OF HEALTH ,�, �� APPLICATION FOR LICENSE/PERNIIT - 0 , � f .��c�adr�o * Please complete form and attach all necess e8en er IS 2� '�O 11 Failure to do so will result in the return ' ur atron pa cet. ESTABLISHMENT NAME: � L T LOCATION ADDRESS: � � � TEL.#: O MAILING ADDRESS: S�isz Lr OWNER NAME: CORPORATION NAME(IF APPLICABLE):1 �6 ; G� MANAGER'S NAME: ��lQ�¢([��F�U� � .fG�i� T L.#: �'�fjw� MAILINGADDRESS: �'�g�tf POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) aad attacb a copy of the-certificar�on to this form. - 1. /X�[� 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary 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 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 certif'ied as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certif"ication to this application. The Healt6 Department will not use past years'records. You must provide new copies and maintain a Pile at your establishmenG 1. /u�f4- 2. PERSON IN CHARGE: �ach food establishment must have at least one Perscn In Chazge(P1C) on site duruig fiours of opera[ion. 1. /Y�¢ 2. HEIlvII.ICH 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 tnnes. Please list your employees trained in anti-choking procedures 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 your place of business. 1. /u�v¢ 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN . $55 ��y _CAMP $55 _SWIMMWGPOOL $SOea. �LODGE $55 �a~b" 1 _TRAII,ERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 RETAII.SERVICE: —RESID.KI1'CHEN $80 C.ICENSE REQUIRED FEE PERMTf# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.h. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.fr. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAMECHANGE: $15 AMOUNTDUE _ $ 55.00 •***"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'�** . , 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. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFILIAVTI' SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior t enewal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISfIM�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place 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 uansient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. a 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 Department prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea until the pool 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, 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 OPEIVING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify 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 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 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 appmval from the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernvts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvvIEENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETCJ, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIl2E A SITE PLAN. DATE: j/��= %�_SIGNATURE:��,.,,tf � - � PRINT NAME&TPI'LE: ��1Qi4�� .i+�� /� ��f� �� Rev.]0/25/ll � . � The Commonwealth of Massachusetts Department nf/ndusuia!Accidents M/C�N� , 600 Washington Stred, f"Floor Boston.Mass .011ll � . . Woticers'Compeasatioe ImanaerAftldavk:. . . . . .. •..�.�. �:!�.� .' � �:�.. :• ,"' . - �t 1�hreatlM: Meue�RaVT Ied6H ' � , . - , _ , . ,. � - ._ . �_ .�� v�� addtess�9_�f�CL_-71-'- —.- � ci �� 11�!/�� state: //{�/'f� � � � �o:o�toy� o�� sag-�8=�.sy� work site locatian(fn(1 ad�6'essl: � O�j am a homeowcer perfoiming all work myself. �I am a sole proprietor and have no one wocking in m�y ca�ciry- ❑ I am an employer providing workecs'compensation for my employees wodcing�this job. comouv nmc . . � . . . addrar eHr' ohme N' Imvake ea oatin 6 � ❑ I arn a sole proprietor,geoerai to�tractor,or bmrnw�er(cude ua�)ard have hirod ihe coetracto�s listed below who have the following workers wmpensation polices: � mmm�v o��e• addres• 51�e . o6ase!!• iesv+�ee ea oWlev# . . �ll►noe- �' CMT. p�w- _. _. �l4a�eeCo. _. _. . __.•__._ - . . _... _. __—.–_____ .OUtie�� ._- ___ - _.._ ___ ,�,rrrrr.rr.....t Fuve w xc�e e.eraac e.eqd.ee oav senw nw.tMCL tu m r.r a ue I�.rIW.tatWd pe�wn.r.a.c q a s�3M-N aw.r eee 7en*'ImPrlwa�e�t u we1 n dH pwMb Is t�e fir�da 37'OI WORK ORDBA uA t 9u df1M.N a day iplut�e. I mdenhW trt• ca�y s[Hh Wee.eet�y he 6nuMM b Ne Omce af IwMItYNr�f Ue DIA Rr ar�en�e ver�nW�. /lo hereby nrd� e ds nd 'tlea o rfrry t1Yd Nis tefonM�provifel e6sve 6 pue ad cormt r s�s� n,x �/�—��1�p Prim name � Phone M ��^ �i�D /�� `�l�J , .facw.ex.ay.. ao..c nrife o.tw.re.a ne�o.pkYea ey.dry or rwa.ekW . . . . .. . . . .�eity sr towo: � , . . . PvmM�9eeos X . � . . QBntdMR DeParden�. . � ❑<hedc If Ima�1e teapsne 6 rcqoi�ed �+�q8a . ❑IIeNY Deprde� caata¢t penoa: Py��A: �Q lm�saa mm�