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� TOWN OF YARMOUTH BOARD OF HEALTI� `� ' ;
� � r�PPLICATION FOR LICENSE/PE;R1�I�-;&ry�0� �; �°` � P�^�Y 2;; f �';'�' ;
�. .�. �,� C�� �
* Please complete form and attach all necessar.�>docu�i�rients byDec er�5 2D11 � + . „�
Failure to do so will result in the return of your a . " "`
ESTABLISHMENT NAME: l��� ' � —
LOCATION ADDRESS: �U�7 / � � T L.#: G `- • a'��
MAILING ADDRESS: , O�
OWNER NAME: �
CORPORATION NAM (IF LICABLE):
MANAGER'S NAME: TEL.#:
MAII.ING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Q erator�s) antl a�tae��copy of t1�e e��tifieatinn tc�-this form.
1. � 2.
Pool operators must list a minimum of two employees 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' 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 are required to have at least one full-time employee who is certif'ied as a Food
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 establishment.
�. NI�- 2.
PERSON IN CHARGE: _ __ _ __ . _ _ _ ;
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
1. �/�1l� 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-choking 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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABW $55 _MOTEL $55
,�INN $55 _CAMP $55 _SW�'IMING POOi. $8�ea.
1LODGE $55 �L� / _TRAII.ERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $85 O CONTINENTAL $35 ��r 7� _NON-PROFTT $30
_>100 SEATS $160 _COMMON VIC. $60 _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.fr. $225 _VENDING-FOOD $25
_<2,5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO • $95
rraME c�vcE: $is AMOUNT DUE _ $ ! � �
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Q� � ���
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ADMINISTRATION
� �� •
Under Chapter 52,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 t�TTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED ANB SIGNED, OR
CERT. OF IN�URANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK
APPROPRIATELY IF PAID:
YES -v'.., NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall 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 shall 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
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPE1vING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days
prior to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected
and opened.
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 CLO5ING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of '
closing. '
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
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.
CATERING POLICY: .
A,nyone who caters within the Town of Yarmouth 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.yarmouth.ma.us under Health Department,
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:
`?��tsid�c.afes(i.�.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outd�or cooking,preparation,or display of any food product�y a retail or food service establishment is prohibited.
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 201 L
ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS Y REQ IRE A SITE PLAN.
,,
DATE: C ��� I�L SIGNATURE:
PRINT NAME&TITLE: �
Rev.10/25/ll
� �
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�"� The Commonwealth of Massachusetts
. _ -Depart�nent of Industrial AcciJents
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600 Washingto�Street, 7`"'Floor
Boston,Mas� 02111
Worlcers'Compeesatioa Insarance AiRdavit: �
Aunikat I�ir�tMa• Pt�ase PRINT keibh
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address:
city state: zip: �hone#
work site Iceation(fiill�ldressl:
❑ I am a homeowner performing all work myself. '
❑ I am a sole proprietor and have no one wodcing in any capacity.
❑ I am an employer ptoviding wotkets'compensation fa�my employees worlcing on this job.
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address-
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❑ I am a sole proprietor,geoeral co■tractor,or�omeowner(circle owe)and have hired the contractors listed below who have
the following workers'compensation polices:
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CERTiFICATE HOLDER C!lNCELLATION
iS09)77�j-2382 $HpULD ANY Of THE ABOVE DESG�Eq P�LlClES BE CANCEILLD BEFORE
THE EXPIRATION DATE 7'HERffi0!^, Nb7fC� WILL BE O6LIVERED !N
T01�i o� YiZ14ot��s ACCGRDANCg VWTFI'rHE P01.l�Y pROVI5li1NS.
X3xm�uth, MA 02673 ----
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� May. 31. 2012 2:43PM GRANITE PROF'�SSIONAL I�SJR.ANCE No, 5444 F, 1/1
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' � CERTIFICATE aF LIABILITY [NSURANCE DATE(MMIDDlriYYj
05/31112
THIS G�RfIFICA7e IS ISSUEo AS A MATTEa OF fN�OWNATION ONLY AN� CONF�aS NO R1GHrS UPON 7NE CERTIFICATE HOLDER. THI8
CERTIFICATE DOES NOT AFFJRMATIVELY OR NEGATIVELY AMEND, EX7END OR ALTER THE COVERAGE AFFORDED 8Y 7HE POLICiES
BELOW. 7HI3 CERTIFICATE OF IN3URANCE DOE3 NOT CON3TI7U7E A CONTRACT BETWEEN THE 133U1NG lN3URER(9), AU7H�RIZEO
REpRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLdER.
IMPORTANT: If lhe certillcate holder is an ADDI7JONAL IN9UREp,lhe poiicy�les)musf be endorsed. [i SUBR0C3ATION IS WWVED,gub]ect to
the Eerms and condiiion9 of the Policy.ceriain policles may requfre an endoraement A atalement on this cel�iiicale does not conPer rights to the
cerl�Fleete holder in I�eu oFsuch e�dorsernent s.
PRODUCPR
925-062-8400 C�E�T
Oranite Praf Ins Llc#OC41366 gZ5-062-8888 p�E �uc No:
Brok�rage,(nc, �a��
6600 Koll Center Parkway#1 DO DD E '
Pleasanton,CA 9d588
Edwin Mlnessian 1NBUNER 6 AFFORVINO COVERAOE N�ICA
�neuRea�:Travelers Indemn�t Co of Conn
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INBURE F:
COVERAG�S C�a71�ICA7�NUMBER: REVISIQN NUMB�R:
THIS IS TO CERTIFY THAT 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO 70 7HE INSURED NAMED ABOVE FOR THE POLICY PERIOD
IN6iCATED_ NOTWITH3TANDIhf(3 ANY REQUIREMENT,TERM OR CONDITIdN OF ANY CONTqACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIF(CATE MAY BE l3SUED OR M�4Y PERTAIN, THE INSURANCE AFEORDEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS,
EX�LUSIONS AND CONDITIONS OF SUGH POLICIES.LIMITS SHOWN AMY HAVE BEEM1I REDUCED BY PAID CLAfMS.
INBR TypQ OF INSURANCH �o� u POLICY EFF POLICY E P �vali6
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POLIGY PRo- LOC 5
� AUTOAIOBILE LIA6IUTY COMBINED SINGLE LIMIT
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HIRED AVTOS µJTOS �
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CERTIFICAT�HOI.DER CANCElLAT10N
TOWNHAL
SHOULD ANY OF THE ABOVE D€SCRIBED POLICIES BE CANCELLED BEFpRE
Town of�armouth,MA 7HE EXPIRATION DATE THEREOF, NOTICE wILL 6E DELtvERED IN
ACCORDANCE WITH THE POLIGY AROVfSiONS.
1146 Rovte 28
S.Yarmouth,MA 02664 AUTHOIt1Y�0 R�PREBEMTAIIV�
Edwin MinassSan
�7988-2010 ACORD CORPORAT[dN. All rlghts reseroed.
ACORD 25(2010105) The ACORD name and fogo are regfstered marks ot ACORO