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Home My WebLink AboutApplication and WC� - ' � " � � S.2.T2a��P� TOWN OF YARMOUTH BOARD OF HEALTH ( ,, APPLICATION FOR LICENSE/PERMi'T-2010, ,, uC�,�`� ��. , :. _._ � "` Please complete form and attach all necessazy documents by December 1 S 2009. Failure to do so will result in the retum of your applicataon pac�et. � NAME OF ESTABLISHMENT: � c,'v�esL� �� cv � TEL.#t..��'-�'.��-c�� LOCATIONADDRESS: � �. , O.�(� � MAILING ADDRESS: ti 1t�-- OWNERNAME: p _` D FE orS N � � -`� CORPORATION NAME (IF APPLTCABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor 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 this form. 1. �� 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The FIealth Department will not use past years' records. You must provide new copies and maintain a file at your place of business. I. 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 Protection Manager, as defined 'm the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificarion to tlils application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. 7- ' PERSON IN�HARGE:- - - - ___ _ . . Each food es�hwent must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. T 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 emu�ployees trained in anti-choking procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. Yon musf pro 'de new copies and maintain a 51e at your place of business. 1. /V�� 2. 3. ' 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICEIdSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 ,�L*IN $55 _CAtyII' S55 �SWIMMINGPOOL 380ea. _LODGE $55 I TRAILERPARK $105 ��0 "OO�i _WHIRLPOOL $80ea. FOOD SERVtCE: LICENSE REQUIRED FEE P£RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'f# _0-100 SEATS S85 _CONTINENTAL S35 _NON-PROFIT S30 �>I00 SEATS $160 . _COMMON VIC. $60 �WHOLESAL£ S80 REiAII.5ERVICE: —RESID.KITCHEN Q80 LICENSE REQiJ1RED FEE PERMI'C# LICENSE REQUIltED FEE PERMI7# LICENSE REQUIRED FEE PERMI I# _c50sq.R $50 >25,OOOsq.ft. $225 _VENDING-FOOD S25 _Q5,000 sq.ft. . $80� � - _FROZEN DESSERT $40 � . . TTOBACCO $55 xn�cantvcE: sis AMOLTNT DUE _ $ I OS_o,� ..«««pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""** R ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYazmouth 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 CeRificate of Worker's Compensation Tnsurance. THE ATTACHED STATE WORKER'S COMPENSAITON INSURANCE . AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR 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: YES_� NO MOTELS AND OTHER LODGING ESTABLISHA�iVTS TRANSIENT OCCUPANCI': For purposes ofthe limitations of Motel or Hotel use,Transietrt occupancy shall be limited to the temporary and short term occupancy,ordinarilq and customarily associated with motel and hotel use. Transient occupazrts must have and be able to demonstrate that they maimain a ptincipal place ofresid�ce 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 dweliing unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupaucy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as aznended, shalt generally be consideted Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins by the Health Departmem prior to opening. Contact the Health Departmem to schedule the inspection three( )days pnor to opening.PLEASE NOTE: People aze NOT allowed to sit m the pool area until the pool has bezn inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,totai coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, aad quarterly _ thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('n days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters witlun the Town of Yarmouth must notify the Yarmouth Health Departmern by filing the required Temporary Food Service Application form 72 hours prior Yo 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 certi6ed lab. Test results must be sent to the Hea1th 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 approval from the Board ofIiealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product�a retail or food service establishment is pro6ibital, NOTICE:Permits run annually from ianuary 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETCTRN TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL KENOVATIONS TO ANY FOOD ESTABLISHMENT, 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 REQUTRE A SITE PLAN. DATE: ' O SIGNATURE: �' � �;�M _ �� <}�2�./ PRINT NAME&TITLE:��io.r?i� I��?1L� iL�� 09/25/09 i ' �\ The Cowemonwealth of Massachusetts Depar[rnent oflndusTria[Accidents M�CI NM� 600 Washington Street, ��F(oor Boston,Masc 02111 � Workers'Compeasatios fesaraace AI[davit.Baildiog/Plambisg/Eleetrical Coolmtors� - - � . t .. . � � . . . �. � . name: 7��7�i�YI , � (��L��--� � .. aaa�s �c � �ti i f( l� �� 1� i � �I 1)� ✓— sate• /7/� � � zio��"�� nhooe# -�L/(J — �( r�CL-'� � woflc site location ffull addressl: ` . . . � ❑ I mu a homeowcer perfo�ming all waak myself. Project Type: ❑New Conshvcbou❑R�odel . [y�'��a sole�proprietor and have no une wodcing in az�y�capacity. ❑Building Addition � ❑ I am ao�pbyer�aoviding woikecs'fompensation faa my emplo�ing this job. � ae� � �aee: /'. �_ - �'. `<. .. � yk�. � . � . . . . � � . - � � . . . . . �� ; �� c � �/ c��' � � � �- .5U8- � � - �� , �. �. � ' a 5 •C� , - G .:-.. .. . �.`� `Y'� s :.' .�..�� . - y . ..,.. . ..._�.. .y'S£... .Y'fi�. � fx::i>Y '=VaA`t ...�.$+ eN§df..�Y :`:: ❑ I am a soIe .:�.'�e�oy ge�eral ee�traetor,or iomeaw�v(circle am)and have hired the c:ontrac[as listed below w6o have the following walcets'compensaflon pulices; � � . camm�r�anr. - � . . . . _ � .�. . . ddrw:. . .. . � . . . . . . . . � � . dh: . . . . . . . _ �R' � .. . . . . , . . . . mea�xca � _,, .. .. . ,_ ��'T�_ , _ . � .�,. _.=�x-�;�`.�s,�„,.� . owwi�me_ � . addren• � . . � . . d4f:� .. . .. . . . . . - . � �oYweg� . .. . . - � . , . . _ . ._— --- -� � �� ---- - — -- - --- --- -.---:_ - , ... : �:. , ..i�;�, ��. :., .._,. �' R:S*.�.^';:'� �.;s .,gr v �.>:� . 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