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Home My WebLink AboutApplication and WC i ' , � i�� a TOWN OF YARMOUTH BOARD OF HEALTH ' �� APPLICATION FOR LICENSE/P e. � �� ,i�� Z�� * Please complete form and attach all necess ` c fi � �CQ►n er 'DEPT. Failure to do so will result in the return of your applicahon pa - ESTABLISHMENT NAME: .rC�s `' ID� 6 — 66S=1° LOCATION ADDRESS: 9� ��S' ��'ot lYI�G� �/`Y/d�� TEL.#:C S"��9��/�� MAII.INGADDRESS: Co,wiQ c� S o�✓�t OWNER NAME: CORPORATION NAME (IF APPLICABLE): t �Q 7� /tQ //C , MANAGER'S NAME: TEL.#: C- —0 �/ MAII.ING 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 cuttendy 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�le 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 certif'ied 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 Pde at your establishment. i._��N�� z. }��-o c4-1,6�/✓ L�.)�1�G/ PERSON IN CHARGE: _ - - Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. i.��o �t'�Nf� Cr�,� 2. � (� c�.(�i,� fn��rl✓L� 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 'm 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. �� f�� 2. 3. 4. RESTAURANT SEATING: TOTAL# �oncmrc: OFFICE USE ONLY LICENSE REQUII2ED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMINGPOOL $80ea � _LODGE $55 _1R�_u pARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# IO-IOOSEATS $85 '�ra-05� _CONTINENTAL $35 _NON-PROFIT $30 � _>1005EATS $160 �COMMON VIC. $60 a� ;� _Wgp�/� $gp RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.h. $225 _VENDING-FOOD $25 _<25,000 sq.h. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAMECHANGE: $IS AMOiJNTDLIE _ $ I�kS.bn •x***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'�"�'�' 1 ADMINISTRATION - II ( 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 COMFENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMI'. AFFIDAVTT SIGNED AND ATTACHED ' Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK � APPROPRIATELY IF PAID: I YES� NO 1MO�L8 Al'�I3 OTZ3�R�,(3DGING��T�,BLISf�14ENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be I 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 aggegate 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. i POOLS i 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 prior to opening.PLEASE NOTE:People aze NOT allowed to srt m the pool area until the pool has been inspected and opened. POOL WA1'ER 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. � CATERIlVG POLICY: I 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 Deparunent,or from the Town's website at www.yarmouth.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 Depaztment. 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: I' — �:�c�{i A:;e�,:t�o:seatiag�ri�h w�i?�r,haai�Pss serv�ea),rmust have P'-��FPreva�from t�Boazdef Hsalth. i I OUTDOOR COOKING: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited. �I NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2011. , 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 COMIvIENCEMENT. RENOVATIONS MAY REQUIlZE A STfE PLAN. DATE: b I �,SIGNATURE: J(''Z C�� b'li"' ' �� ✓ �. PRINT NAME&TTI'LE: Rev.10@5/t 1 . � The Commonwealth of Massachuselts Deparbxent of Induserial Accidents N�CaN�tl�a 600 Washington Stred, 7"Floor Bostoa,Mass. 02111 - . . Worlcers'Compe�satios Iroannn AftldavN:.. � . �. . .. . �N I�irmtlw: Pkae PRQIT�dAlt „�: C�+rN � 1NN �s: cirv _ state: zio: ohone# work siM 1«afion(full addressY. � ❑ I am a homeowmer perFotming all work mysetf. ❑ I am a sole propridor ard have eo one working in any capacity. � . - ❑ I am an�nployer pmviding wodcas'compensation for my employees wo�king ou this job. :,_-�, _ � , . : fAmD1�7Yme: ,�<-.r. ., . . �_ ;'as,_. -�..-..� _-. ..,d-..': r,.F..+�7Yi'YJ . i�d' eitv- oYoee k- �ce. oatle�8 �E� !'f� �/�� ❑ I arn a sole proprietor,ge�enl e�trxMr,or Y�eow�er(circ/t onel�d have h�rad t6e conUactas listod below who�have We folbwing warkers'wmprnsation polices: � . eomoar noe• . . ad�aa• tilY' Mwe N• Ie_sQa�te ca . . . . notlev M eaeoa��une- Wdrlsr cttf- oYe�e AF . _. . . - - - - � ---__._--- -- -- -- - --- -. . . .-- - -- - _ _ _-----_ _. .. ------ -- ��eeeo � . . _.. . _. oaliev/ . . �.+r�rrr..er....rT FaYvs Y aecve O�+vYe s rtqdred ude 3MIN 2SA dMGL LS2 n�Ind b He i�pa1W dvidW psYtle�f�me�b f1.BKM a�il�r o�eyan'Iy�rYweesta��dndNpmltlnhWehr�o(a3TOTWORKORDeAud�medSlM.MadryaphMsa I�NWt• eapy�tNh Nate�eM o�y bc hrw�Nd 1�the O�a dl�sr af IYe DIA Rr cmnee ve�nlM�. �Jo Aaxey n.eyy rere.Me p.4.s.w/pe�..r8«olv�l�r u'a Me rwfe.,.dlon prrd/e/.eu«e v b.e mis a. / a s�� C_'�.e,0 6-'�,�^-ti 1--�`, ne� � 1 ��?/� / �� Prim name Phone M . efBeYl ese wy do aN wrNe i�16b a'n N 6e covPkfd 67 dlY r bws�c61 - � � � . cLLy er�.wn: � . .perdtlticese r r1e■Ydbs Dep„�eet ❑chedc Iflomedl�t roquese h re9� �'s Olsee ❑Nd1Y DeptOet rorfaat penea: PY�e y: Op�ge pa+id Sqi mml NOTICE � NOTICE � "r0 TO �� _ EMPLOYEES EIVIPLE.IYE�S �� -. . The �or��rno��ea�t� a�'� l�a��tts DEPARTM�1�tT QF IN�J�ISTRIAL ��E�IT'S � 600 Washit�gt�n �treet> Bostan; Massachus�t�,,(�1�1 � 61?�72'��,49IX} -http://www.rrtass�go'�cfi�c;� : ��, I As required by Massachusetts General Law, Chapter 152, Sections 21,22 Fc 30,this wiltg[ve;yon notice that I (we) have provided for payment to our injured employees u�der the atiove?tri�ndafiet�chapter by insuring with: PUBLIC SERVICE MUTUAL INSURANCE COMPAN�Y NAME OF INSURANCE COMPANY ' One Park Ave New York, NY 1Q01& ADDRESS OF INSURANCE GdMPANY' WG-022209-11 05/30J2C}t4, _ " t15M3f1/2U12 ro�c�r rrun�a��a ��i��s RICHARD SQO Hd0'1NSURANCE AGENCY. WC. 1148 WASHINGtON STREET BOSTON MA 02118 ,��t�� i8B NAME dF INSURANCE AGENT ADDRESS � P�if1NE# Fine Asian Cuisine, Inc. , EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFETCER(IF ANY} 17RTE MEDICAL TREAIIVII:11i� The above named insurer is required in cases of personal injuries arising out of and iu Ehe coutse of: employment to fumish adequate and reasonable hospitai and medical services it�at�ord�nce with E6e provisions of the Workers' Compensation Act. A copy of the First Report of Injvey musE la��iven to the injured employee. The employee may select his or her own physician. The reasoeabte costaf the ser- vices provided by the treating physician will be paid by the insurer, if the oreatmentis neeessary and reasonably coonected to the work related injury. In cases requiriug hospital attention, employees are hereby notified that the insurer has arranged for such atten6on at the NAME OF HOSPITAL ADDRESS TO BE POS'I'ED BY EMPLOYER