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Home My WebLink AboutApplication and WC : -- �ra1�- ��,ll '.': .: � TOWN OR YARMOUTH BOARD OF HEALTH �p��p i APPLICAITON FOR LICENSE/PERMIT-201 0" NO/ (1,., � a j "Please complete form and attach all necessary documents by Decemb 1 •H t;t r , . � F az l u r e t o d o s o w i ll r e s u l t i n t h e r e t u r n o f y o u r a p p l i c a U o n p a c . NAME OF ESTABLISHMENT: �s�/¢s'� iC��EyP �nd�� TEL. #� �O.S�/D LOCATION ADDRESS: �5�'� ST .S'�u��las�ff�✓�. ��(�,�y MAILING ADDR�ESS: S � OWNER NAME:l/�.vi4f�i/, rss�� G, TAX ID (FEIN or SSNI•!� /'-//�(] CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: cL ' TEL. # ��T� MAILING ADDRESS: � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State 1$w. Please list the designated Pool Operator(s) and attach a copy of the cerrificarion to this form. _ _ _ _ _ 1. _ _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 Departmeat 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 are required to have at least one full-time employee who is certified as a Food Protecrion 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 maintain a file at your establishment. 1. 2. r— PERSON IN CHARGE: ---- - -- _ _ _ . - - _ _ - - Each food establishment must have at least one Person Itt Chazge (PIC) on site during hours of operation. 1. � 2. HEJMLICH CERTIF'ICATIONS: 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 enployees trained in anti-chokwg 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 t"ile at your place of business. 1. 2. '— 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQtIIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# _B&.B $55 _CABIN $55 _MOtEl S55 INN $55 _CAMP $55 �SW)MIdINGP00L 580ea. �LODGE $55 O-OO _TRAILERPARK $105 _WHIIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PEBMIT# UCENSE REQUIItED FEE PERMIT# LICENSE REQiJQtED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT S30 _>I00 SEATS $160 ,COMMON VIC. $60 _WHOLESALE S80 RETAII,5ERVICE: —RES[D.K[TCHEN 580 LICENSE R£QUIRED FEE PERMIT# LICENSE REQUIl2ED FEE P£RMIT# LIC£NSE REQUIRED FEE PERMIT ti _<SOsq.ft. S50 _>25,OOOsq.ft. $225 _VENDING-FOOD S25 Q5,000 sq.ft. $80 _fROZEN DESSERT $40 TTOBACCO $55 NAME CHANGE: SIS AMOUNT DUE _ $ S5.00 � '•""•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'*^** AD�STRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WOI2KER'S CO�YIPENSATION INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taa�es and liens must be paid prior to renewal or iasuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: / YES NO //� MQTELS AND OTHER LODGING�STABLI,SH114ENTS TZ2ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordiwarilq and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place ofresid�ce dsewhere. Transient occupancy shall generally refer to corninuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety(90) days within any six(6)momh period. Use of a guest unit as a residence or dwelting 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 insp�� by the Health Departmetrt�prior to opening. Contact the Health Departmem 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 baen inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate cowrt 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 sevett('I)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmeart by Eling the required Temporary Food Service 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 lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit wrtil the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seafing with waiter/waitress service),must have prior approval from the Board ofFiealth. OUTDOOR COOHING: Outdoor coo_king,preparationzor display of any foodproduct by a retail or food service establishment isprohibited. NOTICE:Pernrits run annually from January 1 to December 31. TT IS YOUR RESPONSIBIIITY TO RETIJRN TI� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. AT"T" RENOVATIONS TO ANY FOOD ESTABLISH1vTENT, MOTEL OR POOL (i.e., PAIIdTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY T'I-lE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUTRE A SITE PLAN. / � DATE: ��C(�-� �� SIGNATURE: ��`� , ��,,�� PRINT NAME&TITLE: GgdQ�9lcli.wE'.2,iPasFu� �.�_o�✓, 09/25/09 �\ The Commonwealth of Massachusetts Department oflndasdia/Accidents �N� 600 Washington Street, �"'Floo� Bostoi+,Mass. 02111 Worlcers'Compeesatioa iasvaace At[i�vih Bailding/Plembisg/Ekctricai Cootractors � �_ ,(�i�ss ��v��C ��4L� �s: ,�8' /�/G"/�1•�.'� ST � �'��f,�R°.L��/�i`t smre� /e� � uo� U?�LQ/� �a S�-0`5'Ua ��s � r�u�. am a homeowcer perfocming all wa�k myself. � Project Type: ❑New Coastcucti�❑Remode! I azn a sole�proprietor and have no one wocking in ar�y�capxity. ❑Bwlding Addition ❑ I am an�pbyer providing wakas'compensation for my employees wodcing ou this job. coeoa��e: - ,._ ' .. . . : __ .: . . addras' � .. . . � . . . �ettr• � . oYo�eN-� � . . . lat �. - :., . . �..n:�..,.a .r> .r. ., - . ��', .. � :., _ - � -� i�-s.. ,.�.�: . ��.3�.�'s as'�'�: ❑ i am a sole propriefor.Se�aal eo�traetot,or iomeewwv(cirde aee)and have hired U�e co�ac[aszlistad below who have the following wakas'compensa4on polices: - . . coeorv�aor. . . . . . . . .. - - . . � ' ad�t4n. . - � � - d4'e � . � . : � � � oka�eM• . . .. . . . . � . . . , .tueatoed.,:._ ... . .,. , . .. - . �� . . . . . .. ... . .. , _ . .��,r. .�:a .�'�„" ��t �4� addren: . d�fe� ... - ; . . . . . . . . - . o►eee�-_ . .. . . � . , . ___ ._- _ —._.. ____—_ .._—.. _. __ ._ . _.� . —___ . .. � - ^ .? _s 5��-`,4S.S..,a'c..3F:=��. ,`§4... `�_:f'u�++e'i,�`%Fc�i� . 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