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Home My WebLink AboutApplication and WC . : � J�^ �b' a TOWN OF YARMOUTH BOARD OF HEALTH ' �� APPLICATION FOR LICENSE/PERMIT,•-2 �I �i � ... n�(, , �� * Please complete form and attach all neceSs�aiy;� � cem er 'DEPT. Failure to do so will result in the rei'iun a ion pa . ESTABLISHMENT NAME: � ' Z� I�R�v 11 C AX ID: LOCATION ADDRESS: TEL.# �- � S-� �l Mau.uvc aDD�ss: R •- �,u � - a OWNERNAME: � � 2 ��(a (�Y�bU CORPORATION NAME(IF APPLICABLE : MANAGER'S NAME. �Z 1JfiQ 1 r2 -1?A S�3 QR'EL.#: $-� MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification 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 Cazdiopulmonary 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 certified as a Food Protection Manager, as defined in the State Sanituy Code for Food Service Establistunents, 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�le at your establishment. 1. 2. „ PERSON IN CI-IARGE: _— _ ___ -- _ _. _ -_ _ _ _ _ _ - - _ _ _ Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich Maneuver on the premises at all times. Please list your employees uained 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�le at your place of business. � 1. 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 M07'EL $55 _INN $55 _CAMP $55 _SWIMMINGPOOL $SOea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMTf# LICEIVSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0.100 SEATS $85 �ra-CSD _CONTINENTAL $35 _NON-PROFIT $30 _>100 SEATS $160 I COMMON VIC. $60 ��f� _WHOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDIIVG-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $IS AMOi1NT DUE _ $ I 4 S .�O •*'x�pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM$xxsx , > , ' ADNIINISTRATION 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 � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE I AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF INSURANCE ATTACHED I OR i WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO 1FfOTELS Ai'4�'� OTd�'ER LflD�I;YG�.3TA�LI3HMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinazily 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 I 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 i Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. � POOLS POOL OPEIVING: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.PI.EASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected and opened. � I 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. I FOOD SERVICE I 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 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.varmouth.ma.us under Health Department, i 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: ' Outsi��fes('r.c:,�,jt�o3rsesting 3r�i�h svaite:h.vaitcess�ervice;,r.:nst h�ve prier appFoval f.rom the Beard of Health. - �, OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �I NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'I'iJRN ' THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED H'EE(S) BY DECEMBER 15, 2011. il ALL RENOVATIONS TO ANl' FOOD ESTABLISfIIV1ENT, MOTEL OR POOL (i.e., PAINTING, NEW II EQUIPMENT, ETC.), MUST BE REPORTED TO AND PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY TI'E PLAN. I DATE: (�- `J � �.� SIGNATURE: � '� PRINT NAME &TITLE: � V.f.,�7u J� .G/I-,�I��A OCl//'✓�' � Rev.10/25/ll II . : � � The Co�nmonwea/th of Massachusetts Departmeat of IndastriaJ AcciJents N�e�Nrws�lNs 600 Washingfoe Street, �"Floor Boston,Mess. 02111 Woricers'Compessatiae Imanaee Aftid�vih�. . � . . . �t 1�termatlM: PMue PRIIVT IeA� _ naroe: h%�5�0� s'[..- ' �.�l�V��. � .. �s—, , �-��=)-5 �'c-2�ia w�1'rl' --- q ciN w' 7"�1.a�J'(�Ft state• �� z�o�<J�7 3 o.�e A 5^�� J �J�O !a 3 � work si4 location(full add�essl: _ . . . . .. � ❑ I am a homoowner performing all work myself. ❑ I am a sole pro�xidor aed have eo a�e wocicing in�y capeciry. � 1 l N5. (�I am an employer providing wo�kers'compensation for my eanployees wodciog on this job. �A'U �'Y �m�..,..�- � �n�i`��C^;2 2- ._: ��'� _ , �i�TC�` -—i��C , sas �a$ rr 9� .�: �,�� (�'r .�t9 �?C�421 �Ji�LO,��l6j . �: 1.0 - �Oa?M.c��.a �m. 5 0� 77 ) �o t o �.o,.a� r�-m .�,�,Sr Noru� �Mc-uucA �.. �T'�/ � � � 5'� �L9 � . , ,_ ❑ i am a sole proprietor,gewil ea�tractor,or�omtow�er(cnde owe)and have hiced the conhactocs listed below who have lhe following w�kers compenvation polices: canmv�• ad�m• cih' n6aee N• (nvaKe ee. oatiev M �T nee- ad�- clts• - ora�e AF — --.. ____— Irva�ee ce. oaLh�i wrr.++rrrwer....r� FaYve Y aetne w�vye u req�d odv 9ee1N�2SA dM[:L 13S n�kW 0�He I�p�tlr da`IW pe�Nle da Ae y b f1,SKN atlhr sse ynn'I�rMent n wH»dN pedltln h 1Ye fx�da 370r WORK ORDBR W�Ne dS1M.N a day apimt�e. !oBmhW tmt• ap��tNh flatrae�l vy 6e firw�rded u He Omce�[IsreMlptlw NIle DIA Rr e��enae ver�. i�tiarer�!'r 9��oIDM�Y Ma NYe Infenwatlon prsvidef ebene/a e�e owJ cermt s�s� ne� D/ - /�/- /02 PriM oame — 'O`� �'2i� P6one k 7 CJO .7 t�� ! a�3� .mew aae..ry a...�wrae r 161..`n a ee ce�pkted M cLLs or Y«e.ekil . . eily or tewn: � pvdflffieeme N I-l8oidisE OR��e� ❑<hedc Ifimvsm4 reepeme 6 rcqdrd ��syR BetN �etm1 Olsue �HeaNY D�� n°fact P'+�' PYMe A: � tm�a s�mao�