HomeMy WebLinkAboutApplication and WC �' a TOWN OF YARMOUTH BOARD OF HEALTH �` ��
��� APPLICATION FOR LICENSE 0 � ' ` � r,�.( 3 G ?O11
* Please complete form and attach all necess oc ��l)ec ' ber I 2011.
Failure to do so will result in the return of your application p e . EPT.
ESTABLISHMENT NAME: C�IIt P�IMII!A16.rC. T.�X ID:
LOCATION ADDRESS: �RL���. TEL.#: S�`�"7�I�Lf�L 6
MAII.ING ADDRESS: �rt Ya1■fnl�� �Tl
OWNER NAME:
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: G�LAI�. �Anni.t5 TEL.#: S��i ` Gy- �70 °
MAILING ADDRESS: 1�� I`�Mv f�-owsr� So ✓ta �/A,r�-fo✓� , 11 A a a 66�f
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operatex(s}�:c:attach-a eapq e€the cePi�ieation to this fat�m-
1. 2.
Pool operators must list a minimuxn of two employees cunently cer[ified in basic water safe[y, standazd First Aid
and Community Cardiopulmonary 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 aze required to have at least one full-tnne employee who is cer[ified as a Food �I,
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 establishmen� t��
1. 2. �
PERSON IN CHAI�GE: -_ --- -- - -_ ��_
Each food establishxnent must have at least one Person In Charge (PIC)on site during hours of operation.
1. 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 trained in anti-chokmg procedures below an
attach copies of employee certifications to this form. The Health Department will not use past years' recor ��
You must provide new copies and maintain a f'ile at your place of business.
�
1. 2. �.�.0
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N �
_B&B $55 _CABIN $55 _MOTEL $55
_IlVR' $55 _CAMP $55 _S�i'll:L*.?IIVGPO^L $30ea
_LODGE $55 _'CRAII.ERPARK $105 _WAIRLPOOL $80ea �.
FOOD SERVICE: ��
LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT#
_0-100SEATS $85 _CONTINENTAL $35 _NON-PROFTT $30
�>100SEATS $160 Ia�O �COMMONVIC. $60 #�o���F�J _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
_125,OWsq.fr. $80 _FROZENDESSERT $40 � _TOBACCO $95
NAME CIIANGE: $15 AMOUNT DUE _ $ 22-0• 00
*****PLEASE TUkN OVER AND COMPLETE OTf�R SIDE OF FORM**x*•
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ADNIINISTRATION j
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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 �I
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSiJItANCE ,
AFFIDAVIT MUST BE COMPLETED Al�S�I�FJb';�R`�''' ,
!: ie�il! ;;n ,'„ �,,., I
CERT. O T.�IE�ED I
OR �
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED I�i
Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PL.EASE CHECK i
APPROPRIATELY IF PAID: I
YES NO '
MOTELS AND OTHER LODGING ESTABLISHNIENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be I�I
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. I
Transient occupants must have and be able to demonsuate 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 I
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 I,
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. I
POOLS �I
POOL OPEAIING: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
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pool has been inspected
and opened. I
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 II
closing.
FOOD SERVICE i
SEASONAL FOOD SERVICE OPEIVING: !
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. I
CATERING POLICY: 'i
Anyone who caters within the Town of Yannouth must notify the Yazmouth 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 Deparunent, 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 Department. 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
Outside cafes_(i.e.,outdoor seating with waiter/waitress service),must have prior anproYal from the Boazd of Health.__
OUTDOOR COOKING: ��I
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �
NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2011.
Ai.i. 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 REQUIl2E A TI'E PLAN.
DATE: ��- a y" �� SIGNATURE:
PRINT NAME &TTl'LE: ���e� !d A�ry�n ierl'�c�P-,T
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CERTIFICATE OF LIABILITY INSiJRANCE °"�`"�"°°'YYY>
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Mc3hea Insurance Agency Inc """'
749 Main Street, Suite H �'�°`^° °��: �, .
Osterville, MA 02655 ^^�:•: '�=ss � � D
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Captain Parkers Pub� InC. •^^•�A: A.I.lf. Mutual ina rance 33758
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668 Main Street �.a�a�:
W Yarmouth, MA 02673 ,.w,,,p,
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