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Home My WebLink AboutApplication and WC a Towiv oF YaxMotrrx Bonxn oF�ai.Tx : G°p C� c,�p M�D , � � APPLICATION FOR LICENSE/PF�R�T -2012 ' . ... � �� '';s' , n , * Please complete form and attach all necessary�locum s by cem r IS 2�I`I.'" ��2 Failure to do so will result in the return o�bur�pplicahon pac t �TH p�P7. � ESTABLISHMENT NAME: Cyl��r� Q,I�P�S� TAX ID:� %� LOCATION ADDRESS: %7� � W� � � ��lU TEL.#: ,SZI '77/' 3`7�y MAILING ADDRESS: OWNER NAME:_ � U �'C. 1�/'/.S�a// i 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 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, standard First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of , employee certifications to this form. T6e Aealth 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 are required to have at least one full-time employee who is cert�ed as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certif'ication to this application. The Health Department will not use past years'records. I You must provide new copies and maintain a file at your establishment • 1. ��I� ��St.��/ 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operauon. 1. �l��i-� CX� S20�/ 2. 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 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 file at your place of business. 1. 2, 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICEtYSE REQUII2ED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMWGPOOL $SOea � _LODGE $55 _TRAII,ERpARK $105 _WI-IIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PYERMTT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-t00 SEATS $85 7f'f�-Ir'� _CONTINENTAL $35 _NON-PROFTT $30 _>100SEATS $160 _COMMONVIC. $60 _WHOLESALE $80 � RETAIL SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.fr. $225 _VENDING-FOOD $25 _QS,OOOsq.ft. $80 _FROZENDESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOLTNT DUE _ $ FS *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORMxxxsa ADMIIVISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut 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 AFI�IDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED Town of Yarmouth taYes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLIS��IENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel 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 OPENIlVG: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.PL.EASE NOTE:People aze NOT allowed to sit in the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd 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 OPENIlVG: 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 Yannouth 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 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: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2011. AT.i. RENOVATIONS TO ANY FOOD ESTABLISHR�NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CONIMENCEMENT. RENOVATIONS MAY REQU E A STI'E PLAN. DATE: � � .> �� SIGNATURE: ^ � ��J PRINT NAME&TITLE: vl I �a O x�.�azsni I � The Coramonwealth of Massachusetts � - , Department ojlrtdusfrial Accidents ' �9fe�N� � 600 Washington Sdeet, Y"Flaor Boston,Mass 02111 Worters'Compeesatioe Irooraaee Aflidavih .. II �i�fifmatln• WdrPRWf N� �: _ u I t-(i L i C6f/ �=--�Ta �c��F�-- ,,q^/ y� �1 CiN �_VC!/�/`(Yn/�'! 1 sfatr 1 !1 f.- zio� Ud'L� ohane# 7 V U �7��'✓�y� woric sih ation full add�os: � ❑ a homeown�perFotming all woik myself. I am a sole proprietor ar�d have eo one wodcing in any capeciq. ❑ I am an employer p�pviding workecs'compeasation for my employees working�tbis job. comm�rme• / Q/Y )� �7[(�(�d0 i addrenc `��. �'C//�� ,.- `/l.t�,��1�ti7r�� YLq- ��- �- `77/-`�%fy r..�.�% �^�GIC--b ��rxry�Rbtri��'1-0 �G2 �.■ OZ/�� 3�a1�9 . ❑ I am a sole propriet�,ge�ersl costractor,or Yomeowner(cirele nwe)and have hired the contracWcs Iisted belmv who have tlx following workets'compensat'an polices: mmmr�- addrm. �• oYase M� � i�svaeee co. ooliev M en�ouv nne• d�pf• clh• � �y. . . iraa�ee eo, oaliev N �,+a�rrr■er.....s FaMee Y aee�e a�eraee s Rqid�ds 3[ctlM 2SA d MGL IS2 m Isi 0�He h�IM taliY p�Nb Ka ie q b f13MM aMlw e�e ynn'imprbon�eet a wd n dH penNW I�tse hr�ota ST�WORK ORD6R W�me atS1N.M a dh�aimt�e, 1 udq�hN Np• eapy NIYb Wtrant�y he 6nurMd b Ne O�a dL�K I�e DIA Rr ar�en`e ve�nW�. . /da hereby eeNfy rnler e peLit owl peiu! � of perfrry tlYd Me IsforamNen prerldel obssWe h ane wd asrrect a b n Signanue � / S( �Y-�t' Date �/�,3 �`2 Print name tII �/S�Q�� PhoM k • / /�' �IBd+�ax osly do oat wrNe 4 thh�ro/a 6e oo�pleted by eNy or 1�ww s�eW cLL�or fewo: permkMeeme N ❑BoidleR lkpvioent ❑epeck Himoem�e'ey�e�e b reqdrN ��t Bwrd ❑Sdxde�'s OIBm 0�� cratffi penos; �y. � t�s.��aw� .