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TOWN OF YARMOUTS BOARD OF�AT.`rH �
� APPLIGATION FOR LICENSE/PERMTF ;�010 .��� �
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*Please complete form and atta:ch all necessasy do�ents by Dec mber l S� 2049.
Failure to do so wiU result in the retum of your application pac et. _ '_._
NAME OF ESTABLISHMENT: ��-��c9<c.l t"�l-t!°� I TEL. # .-�'aS� '7 7 C '���
LOCATION ADDRESS: �f�1�' /�-�k-G 2.�-•� Cu,,�,_Ai•vw.o-•.��. �'�- o� -��3
� MAII.ING ADDRESS:
OWNER NAME: t FE r
CORPORATION NAME (IF APPLICABL ): <<'' j�
MANAGER'S NAME:�„� �t'� TEL. #�� i '"a��
MAILING ADDRES5: S'�
POOL CERTIFICATION5:
The paol supervisor must be certified as a Pool Qperator,as reqnired by State law. Please list the designated
Pool Operator(s) and attach a co�y of the certification to this form.
1. ` Y----� 2.
Pool operators must list a mixiimwm o£two emp loyees currently certified in basic water safety,standard 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' recards. You must provide new
copies and maintain � file at your place of business.
�. a.
3. 4.
FOOD PROTECTTON�VIANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined 'va the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please att�ch copies of certification to this application. The Heatth Department will not use pRst years'records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
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Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All foad service establishments with 2S seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at a11 rimes. Please list your employees trained in anri-chokuig procedures below and
attach copies of employee certifications to this form. The Health Dep�rtment will not use past years'records.
You mast provide new copies and maintain a file �t your place of business.
1. 2.
3. 4.
RESTAUR.A.NT SEAT'ING: TOTAL#
OFF',ICE USE ONLY
LODGING:
LIC�NSE REQUIRED FE� PERMIT# LICENSE REQUIRED FE� PERMfT# LICENS�REQUIRED FEE PERMIT#
„_„_B&B $55 �CAB1N $55 I MOTEL $55 .��o-0.,.�Z
INN $55 ,,,�,.CA1�IP $55 _,y,_SWIMMING POOL $80ea.
_,,,LODCiE $55 �TRAILERPARK $105 ___�___,__ �WI3IR.LPOOL $80ea.
FOOD SERVICE:
LICENS$REQUIRED FEE PERMIT# LIC�'NSE REQUIRED ��E PERMIT# LICENSE REQUIRED FEE P�RMIT#
0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
>l00 S$ATS $160 COMMON VIC. $60 WHOLESALE $80
RETAII.SERVICE: -..�—RESID.KiTCHEN �80
I.ICENSE REQtJIRED FEE PERMtT# LICENSE REQUIRED FEE PERMIT�# LICENSE REQUIRED FEE PERMIT#
�<50 sq.R. $50 >25,000 sq.8. $225 ,___VENDING-FOOD $25
,^„_<25,000 sq.ft. $$0 _..FROZEN DESSERT $40 TTOBACCO $55
NAME CHANGE: �is AMOUNT DUE _ $ 55.o0
*"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**""*
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ADMINISTRATION ;
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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 permit to operate a business if a person or company does not have a Certificate o£Worker's
Compensation Insurance. THE ATTACH�D STATE WOItKER'S COMPENSATION INSURANCE �
AFFIDAVIT MUST BE COMPLET"ED AND SIGNED, OR
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CERT. OF INSURANCE ATTACHED "� :
OR � �
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
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Town of Yarmouth taxes and liens znust be paid prior to renewal or issuance af your perinits. PLEASE CHECK �
APPROPRIt�TELY IF PAID:
YES � NO
MOTELS AND OTHER LODGING ESTA.BLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
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limited to the temporary and short term occupancy,ord�naril�and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maantain a principal pla�ce ofreside�ce elsewhere.
Transient occupancy shall generally refer to continuous occupancy of nat more than thiriy (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
Excise, as defined in M.G.L. c. G4G or 830 CMR 64G, as amended, sb,all general�y be considered Transieirt. �
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POOLS :
POOL OPENING:A11 swimmin�,wading and whirlpools which ha.ve been closed for the season must be insp�t�1
by the Health Department�prior to opening. Contact the Health Departmet�t to schedule the inspection three(3)days
pnor to opening.PLEASE NOTE:People aze NOT allowed to sit�n the pool area.utttil the pool has been inspected
and opened.
POOL WATER TESTING: The water must be tested for pseudomanas,total coliform and staridazd 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 swimrnin�pool must be drained or covered within seven(7)d�ys of �
closing. �
FOOD SERVICE
CATERING POLICY:
Anyane who caters witlun the Town of Yarmouth rnust notify the Yarmouth Health Departmetrt 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. _ ;
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 ta do so will result in the suspez�sion 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 ofHeaith.
OUTDOOR COOKING: ;
_Ou_t__d_oor cooking,pre�axatio�or display of any food product by a retail or£ood servitce establishmen�t is prqhibited._ __ _!
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NOTICE;Pernuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN
TI� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. {
ALL �tEN4VATTONS T4 ANX FOOD ESTABLIS�[IVIENT, MOTEL QR PaOI, (i.e., P,A.INTING, NEW �
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR f
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
DATE: %�-l/�/ SIGNATURE: �
PRINT NAME&TITLE: �z.� - J� U-' - � .�s �-
09l25/09
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The Commoawealth of Massachusetts
Department of Industrial Accide�
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64Q Washington Street, f�Floo�
' Boston,Mass. 02111
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work site location(fiill addressl:
❑ I am a homeowner performing all work myself. Project Type: ❑New Consuuction QRemodel
❑ I am a sole proprietor and have no one working in any capacity. Q Building Addition
�I am an employer providing workers'compensation for my empbyees working on this job.
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