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Home My WebLink AboutApplication and WC � • BRSS �� TOWN OF YARMOUTH BOARD OF HEALTH �� '' '`�i' � '- , APPLICATION FOR LICENSE/PERMIT- 20�`�p�� ._. �r ' � � iS'"� � �: � � 'U`� * Please complete form and attach a11 necessary doc�tfFs� � ��e IS 2010. Failure to do so will result in the return of yo pli �tion pac � H DEPT. ESTABLISHMENT NAME: SS � e r � ��f TAX I :SD - ' O� LOCATION ADDRESS: � 6 ` ��!^ TEL. . � MAILING ADDRESS: OWNER NAME: GE� �� CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State taw. Please list the desienated Pool Operator(s) a�id attach a copy of the certification to thts forni. -- - - L �,��/�� 2. Pool operators must list a minnnum of two employees currently certified in basic water safety,standard First Aid wd Commuuity Cardiopulmonary Resuscitatiou(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 le at your place of business. 1. Z. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food senice establislunents are required to have at least one full-time employee who is cei7ified as a Food Protection Manager, as defined in the State Sanitaz•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 file at your establishment. 1. ��'�" 2. PERSON IN CHARGE: Each iood esta�lishment must have at least one Person ln Charge (PIC) on site duivie hours of operation. I. Z. HEIMLICH 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 times. Please list yow• employees trained in anti-chokuig procedures below and attach copies of employee certifications to this foim. The Health Department will not use past years' records. You must pro��ide new copies and maintain a fi(e at ��our place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGL\G: LICENSE REQUIRED FEE PER�III r? LICENSE REQUIRED FEE PER\41T� LtCENSE REQU[RED FEE PERbIIT� _B&B S55 CABIN S55 D�O7EL S55 _INN S55 CAIVIP � S�i S\k'I�L�IING POOL SSOea. _LODGE S55 . I TRAILERPARK 5105 ��Q _\b'I-IIRLpOOL S80ez. FOOD SER�7CE: LICENSE REQU[RED FEE PER�III'= LICENSE REQUIRED FEE PER\dIT= LICENSE REQUIRED FEE PERNIII'� _0-]00SEAI'S S85 _CONTINENTAL S35 NON-PROFIT 530 _>100 SEATS 5160 COYLbION VIC. S60 RT-IOLESALE S80 RETAIL SER�7CE: —RESID.KIiCHEN S80 LICENSE ItEQUIRED FEE PER�fII'f! L[CENSE REQUIRED FEE PER�11I- L[CENSE REQUIRED FEE PE&bIIl'# . _�SOsq.tt. S50 >25,OOOsq.B. S?25 \'ENDING-FOOD S25 _a25,000sq.f1. 580 _FROZENDESSERT S40 1"OBACCO 555 ��sE c�a�cE: sis AMOUNT DUE _ � I o5 .O o """"*PLEASE TL'R\O�'ER A\D CO�iPLETE OTHER SIDE OF FOR�I"""•" . � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth 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 COMPENSATION INSURANCE AFFIDAViT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes ofthe limitations ofMotel 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 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 aze NOT allowed to su 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 inspection three(3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must norify the Yazmouth Health Departmerrt 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.varmouth.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 Pernvt 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 of Health. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RET[JRN TF�COMPLETED RENEWAL APPLICATION(S) AND REQUIItED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEh4ENT. RENOVATIONS MAY RE IRE A SITE PLAN. DATE:—�D SIGNATURE:��L� .��=�r"// PRINT NAME&TITLE: �`� �� ,Yj �p�g 10%06'10 I � � � The Coramonwea/th ofMassachusetts Department ojindustrial Accidenls N�eaN� 600 Washington Street, 7`"Floor Boston,Mas�. 02111 Workers'Compensatioe Iroaranee ARidavk: goi�diog/Plumbiep,/Eketcicil Coetraetors� � " � name: �L! •e l'� .� . . , � . ��s: �--��--�_------------ s;�. �ass �'�i r �� ' s�« /%� �o �.��6� �� "o S' ��'d.a� ( work site lacation lfull addrtssl: ❑ I am a homeowner perfomung all work myself. Pro�ect Type: ❑New Construction❑Remodel �I am a sole proprietor and have no one wodcing in any capxity. �gui�ding Addition ❑ I am an�np�oyer providing workecs'compencation for my emplo working a�this j_ob. .._ ._. -_ _.. _ ._ _ ___ mmwav me: �(7 S l 17��1(� ,-'{/�I lrn ir � - r'75 �,j�j� � addrns: �nYX �iI// �/(jY1 �� \]� ' ci : ` � 1� e8: (1 -��0 �Q� � ia+ ca � `-�' _e\(�,l q � 0 . . ......,..: ❑ I am a sole proprie[or,geoersl eoetrxtor,or homeowaer(czrc%one)and have hiced tLe conhacta�s listcd below who 6ave the following workers'compensation polices: comwav ume: . . ddrar. citY: ohoae M ieemaeee eo. M eamo.er une: � . addlesr cttr: o�a�e M . . ._.. . _ ._.imeuce to. . . . _ . . . . _ _.... . _ .___. . __ - .uera.aarra.r..er..e...� x F+Bvc b f[ems over�e n eeqehd�adc SariN 2SA sf MGL 152 eu kad b IYe�N'a'lald peuWn da me y b S1�KM�W/�r �rdn•m�p.�o.mr...a,.aw p�.,a�m ie�re..or.sror wowc ortuea m.ee�.tua.a,a,r■We.�.�. �oae,n■a eeW, cspy N Uh slaoemeu m�y be forw�rd[d es the Omae MImW�tl�ro a(tlu DIA for e�veraee rerl6utlx /Jo hereby cerNjy n n Me iu awd pene(ater oJ rj�ry tAat Me Iwfonnallon proviAed ebove 6 pme m�!co Sig�lwe Dah �0�� --�q Q� E ��i Print name 1 �� PhoM k ✓L.�O r�l0 �� . etBeW ax aaly . do ne1 wrke la 1M��rca ta 6e couPktM 6Y d�Y or bwn oHkW . . .. � dry nr e...n• � permiUneeme a penaams nep,rmene . . . ❑check Kimmcdh4 rc�peme 6 rtqdtcd �IJmai�Be�rd QSdet�ea'�016ce ceWact peneo: pYoae M: �HeaNY Dqurtest t�s�mmr �Oua