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Home My WebLink AboutApplication and WC , Bn ss��t�� TOWN OF YARMOUTH BOARD OF HE�.TH �� APPLICATION FOR LICENSE/P�R�T�Ql�� `�' � � � * Please complete form and attach a11 necessary � e sb�Decem �(T1F9�EPT. Failure to do so will result in the return of' r application pac et. ESTABLISHMENT NAME:�/��r/� �i7 cl q�' TAX ID: LOCATION ADDRESS: ��,�f-^rj�7��-pv%s1c.�� o�(o�yTEL #:508=39�P-OS� MAILING ADDRESS: sv'flr1� OWNER NAME: CORPORATION NAME (IF APPLICABLE): � �j p� �s ' c , MANAGER'S NAME: '�Es ' TEL.#:SrJB' 8=r>.S ' MAILING ADDRESS: / � � , POOL CERTIFICATIONS: The pool supervisor must be certiGed as a Pool Operator,as required by State ta�v. Please list the designated Pool Operator(s) and attach a copy of the certification to this foi�rn. I. 2, Pool operators must list a mu�imum of two employees cun•ently certified in basic water safety; standard First Aid aud Community Cardiopulmonary Resuscitation(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 file at your place of business. l. Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one fidl-time enlployee who is certified as a Food Protecrion Manager, as defined in the State Sa�iitaz•y 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 Tile at i�our establishment. 1. Z PERSON IN CHARGE: Each food establishment must have at least one Person Ii1 Charee (PIC) on site durnig hours of operation. I. 2. HEIMLICH CERTIFICATIONS: All food seivice 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 ri�anied in anti-chokmg procedures below and attach copies of employee certifications to this forni. The Health Department will not use past years' records. You must provide new copies and maintain a �le at��our place of business. 1. 2 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PE&bIII�? LICENSE REQUIRED FEE PE&\4II'� LICENSE REQUIRED FEE PER'�SIT r _B&B S55 _CABIN 555� _il40I'EL S55 _INN S55 _!'AM,n S55 _SN1:vMIIQGPGOL S80en. �LODGE SSi (�OO _IItpII,ERPARK 5105 _\LI-IIRLPOOL 580ea. FOOD SER�'ICE: LICENSE REQIDRED FEE PERVIII= LICENSE REQUIRED FEE PER�-IIT= LICENSE REQUIRED FEE PERbUT� _0-100 SEArS S85 _CONIINENiAL S35 _NON-PROFIT 530 _>100 SEATS 5160 _COivLNION VIC. S60 ��HOLESALE S80 RETAIL SER�7CE: —RESID.ffiICHEN S80 LICENSE REQUIRED FEE PER�fII'# LICENSE REQUIRED FEE PER4II'i- LICENSE REQUIRED FEE PER\�IT� _<SOsq.fc S50 _>ZS,OOOsq.ft. 5225 VENDING-FOOD SZS _<25,000 sq.ft. S30 _FROZEN DESSERT S40 TOBACCO S55 �a�zE cxa�cE: sis AMOUNT DUE _ $ S S ,00 *"*"*PLEASE 7LR\OVER A\D CO�IPLE'IE 01'HER SIDE OF FOR�I"•*** a '' ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pernut 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 Town of Yazmouth t�es and liens must be paid prior to renewal or issuance of your pernrits. PLEASE CHECK APPROPRIATELY IF PAID: YES 4 NO MOTELS A.l�?D �'a'�i�it][.JZT�IlS^ E3TA�i.I3II1�1EN'd'S TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shallbe 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 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 inspected by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area 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 OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspechon 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 thereaRer, with sample results submitted to the Heatth Department. Failure to do so will result in the suspension or revocahon 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 COOKING: Outdoor cooking,prepazation,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. TT IS YOUR RESPONSIBIL.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: �0-o6��a � ! � The Commonwe alth ofMassachusetls Deparhxeet of/nduslrialAccidents N/IeaN� 600 Washington Street, �"'Floar Boston,Maxs. 02111 Workers'Compee�atios Iroorance Aftidavit; gaildiog/Piambiep,/Ekctrical�Contnctors . � �matln• Mase PILn�'I'kf)bf� name��'�i� Yi'i L�fl' ��Q"� ��'___��1�'��1-s� ---------------- � ----- - citvS�(i//�C//¢g4��Dv//7L state� 1 (� zio 'I� � oLone# SB� �9i��yf> work site{ocatian(fiill address)_ 0 f am a homeowcer perf'omung all work myself. Prqect Type: ❑New ConstctK:[ion ❑Remodel ❑ I am a sole proprietor and have no one wodcing in any capx�ty. ❑Building Addition ❑ I arn an employer providing worke�s'compensation for my employees wodcing on this job. comoa�v�r. -: .._ _ . ,_. _._, . . - . .. , . _ . . - , - - - - ad�na- clh' oYase k 1mm��ce ca �� ❑ I am a sole proprietor.8eaeral eo�trsetor,or homeovvner(circ%onr)and have hired the conhactois lis[ed below who�have the CoOowing workers'compensalion polices: � ad�s- c(h' o►oss 8 teevaeee to. � mmo�r une- . � . �dP �. Ui�!M -- .. _------ - ._ ---- - ------- _._-_. .__ _. . --- . _.. -------------- -- -- n * . AY�dt Ni�Y�r1 rres�es . FaBve b xcos aa'enR n'Wdrd�tle SMM 2SA d MGL l52 cu Mad b 1�e Isp��(vtsYY . . . . . °�e S�+n'I�rraeeot n wd u dN pcmM4s h t6c bra ef a STOI WORK ORD6R asd�eee dS109.N�i da�,f•ID�e y o�i1.3MM aW�r npY Nt�b�hieaeM my be brw�rded en the Oelee att�vn�d M 14 DIA tar e�ve�e v�rlentln. 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