HomeMy WebLinkAboutApplication and WC� _
I `� � TOWN OF YARMOUTH BOARD O A � �y
��� APPLICATION FOR LICENSE/PEI�[�- � ���i� � Z G�� '
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, * P lease comp lete form an d attach a11 necessary d�me 'Tiq9 "'e i n be IS � �_�� �
Failure to do so will tesult in the return of your applicat�on pack . ` , j
' ESTABLISHMENTNAME: +Q��C-�Z P/-�2/y Z-O�C- TAXID: �
LOCATION ADDRESS:_��S7 • 2?' 2� - W-j�.4Pn�llurz-r ,vN O� )3 TEL.#:S,O$��_(O!-O
MAILING ADDRESS: � �.t! o
OR�NERNAME:�;,i ��,�/�'� i"i Z ��GD
CORPORATION NAME (IF APPLICABLE): �O/V KC� Z /I�� ZO�C- � �G
MANAGER'SNAME: e�saN �e /�.�v„Pi{ TEL.#: 50� 36o9a3,�
MAILING ADDRESS: A1 - S�7-ePs► w/J�l - uJ- S�A?/�vTi� _ M�4 -c9.2� 73
POOL CERTffICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State Iaw. 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 cuirently certified in basic water safety, standard First Aid aud
Commwiity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to tlus forni. The Health Department wili not use past years' rewrds. You must provide new
copies and maintain a �le at y�our place of business.
1. 2.
�. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents u-e required to have at least one full-time employee who is certified as a Food
Protection Manaeer, as defined in the State Sanitary Code for Food Seivice Establislunents, 105 CMR 590.000.
Please attach copies of certification to this applicatiou. The Health Department wilt not use past y�ears' records.
You must provide new copies and maintain a file at your establishment. ,
1. �,.0 L�'T D�/ M. SA�LI.GS . 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site dm-ine hours of operation.
l. 2.
HEIMLICH CERTIFICATIONS: .
All food seivice establishments with 25 seats or more must have at least one employee trained in the Hennlich
Maneuver on the premises at ali times. Please list yow• employees trained iu anti-chokuig procedures below and
attach copies of employee certifications to this foini. The Health Department will not use past years' records.
You must provide nefv copies and maintain a file at pour place of business.
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3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PERLIfI'# LICENSE REQUQtED FEE PERMIT* LICENSE REQUIRED FEE PE&i�III�
_B&B S55' CABIN S55 \40I'EL S55
_INN S55 CA.'�IP S» SR'LbL�IING POOL S80ea.
_LODGE S» _IRAII,ERPARK SI05 _�L`HIRLPOOL SSOea.
FOOD SER�'ICE:
LICENSE REQUIRED FEE PERbII'I= LICENSE REQUIRED FEE PERM['I= LICENSE REQUIRED FEE PER�SIT R
LO-IOOSEATS S85 '�'��'��� _CONfINENTAL S35 NON-PROFII' S30
_>I00 SEATS SI60 LCO'�LvION VIC. S60 O(� _NHOLESALE SSO
RE7AIL SER�7CE: —RESID.RII'CHEN S80
LICENSE REQUIRED FEE PER�fII'# LICENSE REQUIRED FEE PER�SII'- LICENSE REQUIRED FEE PE&�4IT¢
_<$Osq.B. S50 _>25,OOOsq.B. S2?5 �'ENDING-FOOD S25
_<25,000 sq.ft, S80 _FROZEN DESSERT S40 TOBACCO S55
�axE cx.��cE: s�s AI�TOUNT DUE _ $ ��,[}�
`*"*PLE�ISE'ILR\O\'ER A\D CO�iPLETE OTHER SIDE OF FOR\I•***•
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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
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INS[JRANCE 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 pernvts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS ,
TRANSIENT OCCUPANCY: 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 of residence 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 Department to schedule the inspecrion 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 ins�ected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspecrion three (3) days prior to opening.
f'ATERING 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 thereafter, with sample results
submitted to the Heaith 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 Boazd ofHealth.
OUTDOOR COOHING:
Outdoor cooking,prepazation, or display of any food product by a retai]or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBIL.TI'Y TO RE'TUItN '
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. '
ALL RENOVATIONS TO AI�IY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAIIVTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO O D BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. REI�TOVATIONS MAY R A,% ITE PLAN.
DATE: � Z�j -7„p.J SIGNATURE:
PRINT NAME&TITLE: C'�S�� .� M��'� 'CcD o<vnf�`
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• , �\ The Commonwea[th ofMassachusetts
Departnreat of lndnstria(Accidents
N/fe�N�
600 Washington Street, Y"Floor
Boston,Mass, 0211I
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�f I am an employer providing workecs'compensatioo for my employees wodcing on this job.
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CER'TIFlCATE HOLDER CANCELLATON
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