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'. � TOWN OF YARMOUTH B4ARD OF HEALTS �����D
APPLICATION FUR LTCENSE/PERI�+IIT 2010
�.. ���� ��H.�1 i 5 2010
*Please complete form and attach all necessar��oc�u�t�D�ceriib DEPT.
Fai�ure to do so will result in the return af your application pac
NAME OF ESTA�LISHMENT: , sC. TEL. #l�OG- 3r1� ��'3!
LOCATION ADDRESS: _ _ Lc.�.£ 2 �,,.
MAILING ADDRESS:
OWNER NAME: 4 F r S • ,
CORPORATION NAI�IE (IF APPL CABLE): '
MANAGER'S NAME: ,r�.c 6 Q TEL. # S�' 7�� G�
MAILTNG ADDRESS: . .(�' l�i2 i c�- •- o �c
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated
Pool erato s and ttach c of the certific ti n t ' f
Op r( ) a o a o o tlus orm.
�Y
1. 2.
Pool operators m st list a minimum o£two es currently certified in basic water safety,standard First Aid and
Community Car opulmonary Resusci • 'on( �P t}. lease list these employees below and attach copies of employee
certifications to his form. The He h Department i11 not use past years' records. You must provide new
capies and m ntain a file at r place of business.
1. ..
3. 4.
FOOD PR ION�vIAN CERTIPICATIONS:
All food se ce establis ts are req ' ed to have at least one full- ' �loyee who is certified as a Food
Prot�ction anager, as fined in the Sta Sanitary Code fo Service Establishments, 105 CMR 590.000.
Please att�c copies certification to this ap ' ati e ealth Department will not use past years'records.
You must p new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHAR.GE:
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Each food establishment must have at least one Perso� In Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATI4NS:
All food service establishments with 2S seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all tiumes. Please list your employees trained in anti-chokuig procedures below and
attach copies of employee certificarions to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at yaur place of business.
L _ 2,
3'. 4. ,,
RESTAURANT SEAZ"ING: TOTAL#
OFF�CE US� ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMII'#
rs�s $ss �casrrr $ss I Mo�z. $ss �0�a
�.INN $55 �CAMF $55 �SWI��4IMtNG POOI> �$Uea. -
____LODGE $55 �TRAILERPARK $105 �WHIRLPOOL $80ea.
FOOD SERVICE:
LICENS�REQUIRED FEE PERMIT# LIC�NSE REQUIRED �'�E PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $85 1CONTtNENTAL $35 -�(�✓ ___,.NON-PROFI�' $30
7100 SEATS $160 COMMON VIC. $60 WHOLESAL� $80
RETALL SERVICE: �RESID.KITCHEN �80
LICENSE R£QUIRED FEE PERMt'f# LICENSE TtEQUIRED FEE PERMIT�# LIC�NSE REQUIRED FEE PERMiT#
_<50 sq.ft. �50 >25,000 sq.ft. -� �225 +VENDING-FOOD $25
__,_<25,000 sq.ft. $80 ��'ROZEN DESSERT $40 TOBACCO �55
NaME c�vcE: sis AM4UNT DUE _ $ 90 .o�
+►wrtwMpLEASE TURN OVER AND CONYPLETE OTHER SIDE OF FORM"*""*
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ADMINISTRA.TION
Under Cha:pter 152,5ection ZSC, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal �
of an� license or pernut to operate a business if a person or company does not have a Certifica.te of Worker's �
Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATION- INSURANCE �
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR �
CERT. OF INSURANCE ATTACHED �
pR �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
Town of Yarmouth ta,xes and liens must be paid rior to renewal or issuance of your pertruts. PLEASE CHECK
APPROPRI�4TELY IF PAID: �
YES�_ N4
MOTELS AND OTHER LODGTNG ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transieirt occupancy shall be
limited ta the temporary and short term occupancy, ordxnaril�+and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place af residence elsewhere.
Transient occupancy sha11 generally refer to continuou� oc,eupancy of not more than thirty (30} days, and an
aggregate of not more than ninety(90) days within any six(6)manth period. Use of a guest unit as a residence or
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collecrion of Room Occupancy {
Excise, as defined in M.G.L. c. 64�"r or 830 CMR 64G, as amended, shall generally be considered Transient. ;
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. . .. . . . . . . . . . .�... .. . . �
POOLS �
POOL OPENING:All swimming,wading and whirlpools which ha.ve been closed for the season must be insp�
by the Health Department prior to opening. Conta.ct the Health Depaztment to schedule the inspectionthree(3)days
pnor to operung.PLEA,�.E NOT�:People aze NOT allawed to sit�un the pool area until the pool has been insp�
and opened. '
POOL WATER TEST�NG; The watermust be tested for pseudomonas,total coliform a�nd stas�da�d�l&te count
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quazterly
thereafter. _
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)d�ys af
closing.
F40D SERVICE �
,
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CATERING PULICY• i
Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Departme�t by filing the requared �
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
-Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health ,
Department. Failure to do so will result in the suspension ar revocation of your Frozen Dessert Permit untit the ;
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress sezvice),must have prior approval from the Board ofHealth. ;
�
OUTDOOR COOKING: �
Outdoor cooking,pre aratio�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 RESPONSIBIIITY TO RETURN
TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATI4NS TO ANY FfaOD ESTABLIS�:[IViFNT, MQTEL UR POOI. (i.e., PA,INTING, NEW �
EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HE.ALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
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DATE: SIGNATURE: C�,/
PRINT NAME&TITLE: , � ���-�O � ���� �
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U9/25/09 �
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� � The Commonwealth of Massachusetts
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Departmeat of Industrial Accidents
> N11f�I/f�afl�s
60l/ Washington Street, ��Floor
Boston,Mass. 02111
• Workers'Compeasatioa[�sara�ce Aifidavih Baildieg/Plambing/Ek�ctrical Coatractors
A�Ntar�t isfermi4i�: Please 1'RINT keibt+►
name: „ FFU�t �j��,�y
address: ..._`�'�r� ��et UrlCC�C (/•
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wotk site location(full address):
❑ I am a hom�wner performing all work myself. Project Type: ❑New Consfruction QR�nodei
❑ I am a sole proprietor and have no one working in any capacity. Q Buiiding Addition
�I am a�empbyer p�oviding w�keas'compensati�for my employees wodcing�this job.
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❑ I am a sole propri�or, ca�tnctor,or bomeowwer(�rde one)amd have lured tbe�ctots listed below who have
the following workers'compeosation polices:
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