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Home My WebLink AboutApplication and WC( . ��` �:,:� `�:�> ' � ^� � TOWN OF YARMOUTH BOARD OF HEALTH � � � � APPLICATION FOR LICENSE/PERMIT-2621 �' ^ Od � > � : � � " �" 04 �011 � * Please complete form and attach all necessary documents by 'ecdrliber IS �b��. • Failure to do so will result in the retum of your application pac et. ESTABLISHMENT NAME: TAX ID: ( LOCATION ADDRESS: �7 e2 (Lc�I,�I�C 2� TEL # �771 3 µ�Iy MAILING ADDRESS: OWNERNAME: JU,I��e Dvlc!'t>II 9 � �t,SL'c�l 'P�I �ow� CORPORATIONNAME (IF APPLICABLE): �P(.�`CL► IZoSL B/SI ✓tt D 14 hl ('a A C'4le.e� MANAGER'S NAME: �)�,�,{� 2 �V1S(s�l I TEL.#� MAILING ADDRESS:��, POOL CERTIFICATIONS: The pool supervisor must be certi6ed as a Pool Operator,as required by State law. Please list the desienated Pool Operator(s) and attach a copy of the certification to this forni. 1. 2. Pool operators must list a mniimum of two employees cun•ently certified in basic�vater safety,standard Fu�st Aid azid Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this foiYn. The Health Department will not use past �-ears' records. You must provide new copies and maintain a tile at y�our place of business. 1� 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food sennice establishments az-e required to have at least one fizll-time employee who is certified as a Food Protection Manager, as defined 'ui the State Saiutary Code for Food Service 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. i. �1��.��P On�co �� z. - PERSON IN CHARGE: Each food establislunent must have at least one Person In Charge (PIC) on site durine hours of operation. �._ Jr,�,l�� sr.� i�� z.��h ��o m HEIMLICH CERTIFICATIONS: All food service establislunents with 25 seats or more must have at least one employee trained in tl�e Heimlich Maneuver on the premises at all times. Please list your employees ti•a'vied 'ui anti-chokmg procedures below azid attach copies of employee certifications to this forni. The Health Department wiR not use past,years' records. You must provide new copies and maintain a �le at your place of business. l. 2_ 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PE&\4II# LICENSE REQUIRED FEE PER�4IT= LICENSE REQUIRED FEE PERbIIT= _B&B 555 _CABIN S55 J40TEL S55 � _1A1N _ S55 _CAMP S55 � . _S\b'LbL�tINGPOOL S80ea. _LODGE S55 �IRAII,ERPARK 510� �L'HIRLPOOL SSOea. FOOD SER4ICE: � �LICENSE REQUiRED FEE PERbIIT= LICENSE REQUIl2ED FEE PER�IIl"� LICENSE REQUIRED FEE PER�I[T# �0-100 SEAI'S S85 � ��0� _CON7INENTAL S35 NOIv�-PROFIi S30 _>100 SEATS 5160 _CO'�IMON VIC. S60 \�'I-IOLESALE S80 REi.1IL SER�'ICE: —RESID.Y;17CHEN S80 LICENSE REQUIRED FEE PER�fII'� LICENSE REQUIRED FEE PER�U7= LICENSE REQUIRED FEE PERbtIi�= _<SOsq.d. S50 _>25,OOOsq.B. 5225 VENDING-FOOD S25 _<2�,000 sq.ft. S80 _FROZEN DESSERi S40 iOBACCO S55 \A�-fE CHASGE: Sli AMOUNT DUE _ � �{S� **"**PLEASE TLR\O�'ER A\D CO�iPLETE OTHER SIDE OF FOR��I»**'* ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal of any ]icense 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 ' 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 LODGL'VG ESTABLISHMENTS i TRANSIENT OCCUPANCY: For purposes ofthe 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 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 Deparhnent prior to opening. Contact the Health Department to schedule the inspection three(3)days ' pnor to opening. PLEASE NOTE: People ue NOT allowed to sit m the pool azea until the pool has been inspected I 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 inspechon 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.vazmouth.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 ofHealth. OUTDOOR COOKING: ' Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. i�U110E:Permits run annually from 7anuary 1 to riecember 31. I�:S Y�U��2£SPONSIBII.TTY TO P.E':'�TRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 201Q ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, 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 R UIRE A SITE PLA . DATE: �"�I — � I SIGNATURE: PRINT NAME&TITLE: U / 10 06 10 i � � The Commonwewlth ofMassachusetts Deparhnent ojlrtdus[ria!Accidents N/feiNiw� 600 Washington Stnet, 7`"Floor Boston,Mass. 02I1! Worken'Compensatios/roaraeee ARidavk: Baildi�JPlambie�/Ekctricsl Cowtnctors ��atla: �'k�dbh n�: ('r�P ( /� �L� DS iaddrcss: _�ZZ IW�.�.:�� _!i� _ _—..--__.—_--_._.—.—._____ iSiN �� IA i� i�Wl shate /V 6N' zio �7�� ohaee k p5 77��,�'l� work site lacation lfull addnssY ❑ I am a homeowner perf'ortmng all work myself. Rqect Type: �New Construction QRemodel � I am a sole proprietor and have no one wodcing in any capacity, �gw��g p��an ❑ I am an employer providing workers'compensati�fw my employees working on thiy job. commar me: ad�os- c3tY• oYaee N � ia.ea�ee co. oolfev 9 ❑ [am a sole proprietor,geaeral eo�tractor,or 6omeowner(cirde owc)and have hired the cun(ractocs listed below�who�have the following workers'compensation polices: �� • wmo�ov ume• addraf: cih• o�ose N . iesma�ee ce. 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