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Home My WebLink AboutApplication and WCI TOWN OF YARMOUTH BOARD OF HEALTH ��N� �NN � � APPLICATION FOR LICENSE/PERM��' -'2�13 � "� � * Please complete form and attach all necessary documents by Aec ' I�� ' Failure to do so will result in the return of our a licahon cket. Y PP � �. ' �.. L' � .;''i� ESTABLISHMENT NAME: C �W �� I LOCATION ADDRESS: " ou � • TEL. . MAILING ADDRESS: G-ri�2 a1�2 OWNER NAME: CORPORATION NAME (IF APPLICABLE): �%i 11.Q �3��/t C1.�-�S l� r I�t/E. MANAGER'S NAME: X� Ci� �'( G�N wc��w.S TEL.#: �5�� ?9 —�l�T MAILING ADDRESS: St�,n.t G-S `� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated I�ool�pes�eto�sJ and at�ach a oopy olti�e certific�tian Yo this forin. — - 1. 2. Pool operators must list a minimum of two employees currenfly 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. 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 are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary 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. l. �(' i/',.�o c9--"i �11 ��1 2. �� _ _P£i2u�V.'�Id�I�f•:�Gi�',:--- _ _ _ ___ Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.�,�Pn er (1"�,E�,�.in �Ov� 2. �� C�.v ��_a�vl. CLA 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 trained 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. X f 0.0 �� i..lfi�l� � 2. 3. 4. RESTAURANT SEATING: TOTAL# (�� OFFICE USE ONLY LODGING: LICBNSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 INN $55 CAMP $55 _SWIMMING POOL $SOea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea IFOOD SERVICE: L[CENSE REQUIRED FEE PERMIT�#_/ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-t00SEATS $85 #'!3"0!!J _CONTINENTAL $35 _NON-PROFIT $30 . >100 SEATS $160 �COMMON VIC. $60 �S _WHOLESALE $80 . RETAIL SERVICE: � —RESID.KITCHEN $80 . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ I�S. �O . ***•*PLEASE TURN OVER AND COMP[.ETE OTHER SIDE OF FORM***** . ! ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yazmouth 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'5 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 LODGING ESTABLIS�IMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy sha11 be 'i limited to the temporary and short term occupancy,ordinarily and customazily associated with motel and hotel use. I Transient occupants must have and be able to demonstrate that they maintain a principal place of residence I elsewhere.Transient occupancy sha11 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 �i 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected I by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days prior to opening. PLEASE NOTE:People are 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 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 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 obtamed at the Health Department,or from the Town's website at www.varmouth.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 Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut 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:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET'URN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ( � �� 'i'1 � L SIGNATURE: �jG(/n �iµ� ��'' PRINT NAME& TITLE: �A 0 �(it/�i Gl(ko P }-�5<�Q�fi Rev. 10/09/12 i , . � NOTI CE NOTI CE TO tl TO EMPLOYEES �� EMPLOYEES r The Commonwealth of Massachu etts s DEPARTMENT OF IlVDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentio�ed chapter by insuring with: PUBLIC SERVICE MUTUAL INSUR,4NCE COMPANY NAME OF INSURANCE COMPANY One Park Ave New York, NY 10016 ADDRESS OF INSURANCE COMPANY WC-022209-12 05/30/2012 05I30/2013 POLICY NUMBER EFFECTIVE DATES RICHARD SOO HOO INSURANCE AGENCY. INC. 1148 WASHINGTON STREET BOSTON MA 02118 16171 338-8168 NAME OF INSURANCE AGENT ADDRESS PHONE# Fine Asian Cuisine, Inc. EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREAIIV�NT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to fumish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees aze hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER