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TOWN OF YARMOUTS BOARD OF HEALTS [�f'�C S
APPLICATION F4R LTCENSI�`�RM'[T-2010
` i�'�Q �GR 3 0 2010
* Please complete form and attach all necess� �� ������y�?e+c"e � 1 S 0 �t�r`t.
Failure to do so will result in the return a.;�r`applicanon pac ; . '
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NAME OF ESTA$LISHMENT: ,�a�,�w x�-h � ,Bc.Se,!o�) TEL. #`Sv$- 3L 7•13G3 E
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LOCATION ADDRESS: I 3o OId r�+a ;�, S-�.
MAILING ADDRE5S: �,a. 3 o x '��,1 S � Ya�-�.e�-a-�,,._ i
OWNER NAME: T��ID (FEIN or SSNI: E
CORPORATION Nt�ME (IF APPLICA.BLE):
MANAGER'S NAME: �o e ��c e TEL. #,�'dP- ?C7-2363
MAILINGADDRESS: �� O . P�v�,+, 8�1 5� 3/c�.r�s�.-�+., �+ +9 O.�bb�i►
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POOL CERTIFICATIONS: :
Thc pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated '
Pool Operator(s)and attach a copy of the certificarion to this form.
1. � � 2. � � �
Pool operators must list a minimum af two employees currently certified in basic water safety,standard Fu�st Aid and �
Comtnunity Cardiapulmon�Resuscitation(�CPR). Please list these employees b�law aud attach copies o�employee F
c�rtifications to this fortn. T e Health Department will not use p�st years' records. You must provide new f
copies'ancl maintafn a file at your place of business. �
1. _.�, 2. �
3. 4. i
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FQOD PROTECTION�v1ANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Prot�erion Manager, as defin�d in the State Sanitary Code for Food Service Establishments, 105 CMR 590:000.
Please attach copies of certification to this application. The Health Department wiU nat use past years'records.
You mast provide new copies and maint�in a fde at your establishment.
1. �U'�3 �No 2.
PERSON IN CHARGE:
Each food establishment must have at least one Perso�In Charge (PIC) on site durin�hours of operation.
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HEIMLICH CERTIFICATIONS: �
All food service establishinents witb. 2S seats or more must have at least one employee traincd in the Heimlich
Maneuver on the premises at all times. Please list your emmployees trained in anti-chaknag procedures below and
attach copies of employee certifications to this form. The Health Department will aot use past years' records.
You must pravide new copies and maint�in a file at your place of business. f
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RESTAURANT SEAT'ING: TOTAL# �
OFFICE USE Ql'�TLY
LODGING:
LIC�NSE REQUIRED FE� PERMIT# LICENSE REQUTRED FE$ PERMIT# LICENSE REQUIRED FEE PERMIT# i
_,,,_,BBcB $55 ^CABIN $55 _MOTEI, �55 �,
TNN $55 CAMP $55 �SWIMMING POOL $80ea. '
LODGE $55 ____TTtA1LERPARK $105 ______ „_WHIkLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSfi REQUIRED F�E PERMIT# I,ICENSE REQUIRED FEE PERMIT#
�,,.,0-100 S�AT5 $85 ____� _CONTINENTAI, $35 I NON-PROFIT $30 /6���
>l00 SEA'TS $160 �COMMON VIC. $60 �WHOLESAL,E $80
RETAII.5ERVIGE: —RESID.KITCHEN $80
LICENS�REQtJ1RED FEE PERTWIIT# LICEN5E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEItMIT#
<50 sq.R. �50 >25,000 sq.tt. ,$225 VENDIN�-FOOD $25 �
„_,<25,000 sq.ft. $80 � ._...FROZEN DESSERT $40 �TOBACCO $55
` AMOUNT DUE = S �D_ 0 O
NAME CHANGE: $15 ,
� **""*kLEASE TURN OVER AND COMPLETE OTIIER SIDE OF FORM*'�"*"
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�7nder:���52,�Section 25C, Subsection 6,the Tpwn of Yarmouth is now required to hold issuance or renewal
of���iccrise��..p�it to operate a business if a person or company does not have a C�tificate of Warker's
Compensation Insurance. THE ATTACH�D STATE WORKER'S COMPENS�AITON INSURANCE .
AFFIDAVIT MUST BE COMP�ET'ED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED � '
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WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Tawn of Yarmouth t�es and liens must be paid prior to renewal or issua�ce of youi pennits. FLEASE CHECK '�
AFPROPRIAT'ELY IF PAID:
YES � NO
M01'ELS AND OTHER LODGING ESTABLISHMENTS � i
_ T12ANSlENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limit�d to the temporary and ahort term occupancy,ordi,naril�and customarily associated wi,th motel and hotel use.
Transient occupants must have and be able to demonstrate that they mairnain a principal pl�ce ofresidence elsewh�re.
Transient occupancy sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an
a�gregate 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 cansidered transient. Occupancy that is subject to the collectian of Room Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sb:all generally be considered Transie�rt.
POOL5
POUL OPENING:All swimming,wading and whirlpools which ha.ve been closed for the season must be ins��
by the Health Department�prior to opening. Contact the Health De�artmetrt to schedule the inspection�(3)days
pnor to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has be�inspected
and opened.
POOL WATER TESTIrTG: The water must be tested for pseudomonas,total caliform and standard plate count
by a State certified iab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
PUOL CLOSING: Every outdoor in ground swimming pool must be drained vr cover+ed within seven{7)days of
closing.
FUOD SERVICE
CATERING POLICY:
Ariyone wha caters within the Town 4f Yarmouth must notify the Yarmouth Health Departme,nt by�1mg the re�quireti'
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be abtained at the
Health Department.
FR07,EN DESSERTS:
Frozen desserts must be tested on a monthly basis by a Sta.te certified lab. Test results must be sent to the Health
Department. Failure ta do so will result in the suspension or revocation of your Frazen Dessert Permit untit tfie
above terms have been met.
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOI�NG:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NQTTCE: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 1S, 2009.
AI..L RENOVATIONS TO ANY F40D ESTABLISHMENT, MOTEL OR POQ�. (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COA�MENCEMENT. RENOVATIONS MAY REQUtRE A SITE PLAN.
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DATE:_��� � SIGNAT
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PRINT NAME&TITLE: Sv,5�.�I�, L� .""'j ,�„�,�s,K� ���
a9/25/09
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