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� TOWN OF YARMOUTH BO F ALTH r i
� APPLICATION FOR LICENSE�'I? �� �'s - �.�' C"1AR � � GO16 �
* Please complete form and attach a11 necessary cY�G _ en ':';_ ' e r I DEPT.
Failure to do so will result in the return of your application pac
ESTABLISHMENT NAME: G.<. T �
LOCATION ADDRESS: Sau��UC�sf' D/•`t�c- r��,�i /j1Q- 02G .#: ���/2 7. �� 2 ;
MAILING ADDRESS: �Q/��-
E-MAIL ADDRESS: C �tLwi��'+ L�'��fi
OWNER NAME: iIt G �49
CORPORATION NAME(IF APPLICABLE): '
MANAGER'S NAME: ��i� Gv4�d�(lh TEL.#:
MAILING 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 currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the .
employees below and atta.ch copies of their 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 esta.blishments aze required to have at least one full-time employee who is certified as a Food
Protection Mana.ger, as defined in the State Sanitary Code for Food Service Establis�unents, 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.
,
1. �/is�e Cva/Q'�� 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. C�i�c �wl d�v., 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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 fde at your establishment.
l. �%t� Cc�a��i�d n 2.
HEIMLICH CERTIFICATIONS:
All food service esta.blishments with 25 seats or more must have at least one employee trained in the Heimlich
' Maneuver on the premises at a11 times. Please list your employees trained in anti-chokuig 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.
l. 2•
a
3. 4.
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ADMINISTRATION
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 COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �/,�
( CERT. OF INSURANCE ATTACHED
OR
/ WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
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� 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 of the limitations of Motel ar Hotel use,Transient occupancy sha11 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 of residence
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
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
� by the Health Department prior to opening. Conta.ct the Health Department to schedule the inspection three(3)
days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been
, inspected and opened.
1
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 OPEI�TING:
All food service esta.blishments 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:
j Anyone who caters within the Town of Yannouth 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.varmouth.ma.us under Health Depa.rtment,
� 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 Board of Health.
� OUTDOOR COOKING:
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—" I�ep nt c�,�'Fra�tc�a'��t�c�atte�zi�
Ca,�`ace o�'I�vestigc�da�►�
I�c�ngress��reet,�'r�e I�
�ostv�,li�f1Z1.�4-2f�17
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i��rl�er�' �'�mp�ensatia���a�s�xr�atce Affidave�: �ene�al�nsia�esses
.�nnlic���f��r�aa�aa� �'Iease P'���,�
�tisiness/Organzz�tit�n Name: ( ��;�(J."
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A.ddress: � ��� ��t�` ��'F z��`�
�itylStatelZip: %'�.�'"�.;=c:f� ..�.: ° �� Fhc�ne#: ��?�,�..3�.��l�-
Are y,�a an e�ployer?Gheck the appropria#e if�rx: ���3n�T yge(requiret�j:
l.❑ I am a empioyer wi� employees(fult andl 5. �R�aii
or part time).* 6. Q Res#aaratttlBsrlEating Esl�blishment
2.� I am a sole grQpri�or or partne7shig and have no fi. (�Of:�ce andlor SaIes{incl.reat estai�auto,etc.)
� empioyees worI�ing far me in any capacity,
a �, I2`to w�rkers'comp.ins3arance required] 8, j�Non-profit
3.Q 5�te are a ctsrporation and its o#�icers have exercised 9. ❑�:ntertainment ,,���,.-
thsir right of e�cemption per c. 1�2,§1{4),and we have I#�.❑Iv�a�.tfacturing '
�.� no employ�es.j3+To warkers'comp.ir�surance required]* 2 3.[]Health Care
We are a n€�n-profit organization,staffed by voicu�teers,
with na employees.[No workers'cornp.insurance req.] 2�.[�C}t�er
*Any applic�ni that checks box�2 must eIsa fr1i out rhe seaion belnw sbowing their workers'compensation paiicy infosrr�atinn.
*sif d�corpnx�affic�ers have exeanp�d them�lves,but the corporation has other emplayees,a woskke�s'corn�nsstian pniiey is reqvize8 snd ssach an
ffr�atti�rioa should check box#I.
I am rua employer thrrt as pro�iduig wnrkers'eom�ensuti�►n insrc�ttc�frtr�ny er�lny�. Belrtw is rhe prrlicy i�tfe�r�utfoa�
Insur�sc�Campany Name:
Insw�-'s Address:
Cify/�tat�eJ�ip:
Policy#c�r Sel€-ins.Lic.# Expiratian Dat�:
,�t#a�cb a copy ttf�6e xvorkers'com�ssstitut po6'scy d�isr.e�iata p�ge�s6rewing the polity nnmiber and eugara�n dfate).
Failure to seaur�coverage as required under Sectian 25A of MGL c, 2�2 can lead ta the itx�position af cr�minal pe�a�lies of a
ftne up to$I,SUO:�t?and/or cane-y�ar unpriscsnrn��as weI]as civil psnalties in�e fornz of a ST'OP W4RK tJRL7Bit and a fine
of up�$250.U(?a day sgainst ths v°iolator. Be advised that a copy of this st�ate�nea�t rnay be fc�rw�rd�i to the C}f�r,e of
Investigations of t�e}�IA for ansurance coverage verificat�on.
I aCa hereby certrfjr,untler the pau�s rrrad penalt��s a.fPe{yur�'�at tlae ia�,,t'orr�on provided aho�e is true anrd c�rrrec�
�' �r�� ��"��_�� Date f���`���
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Phone#: !���,,�. �` ���.�
t3,f,j�cial use a�ly. IM tertt write in�is arer�tn be enmple�iry ci�r or�riwe�rr,�c�u1
City vr'4'awa: I'ermiifl�.��€ee�se#
Yssuing�la�orily(circte o�ae):
B.�ard of He�tth 2.Saflding Degarts�eaat 3,Cif�+1Tt��n Cierk 4.�.iceusing Boarai 5.S�Iect.�ce�'s tD#jFice
6.Ot6�r
�C€asct�et P�rst��• Pl�a�e#:
www.mssss.govlaia