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TOWN OF YARMOUTH BOARD OF HEALTH �, [-�'�,� i ,`'�"''
-� � � APPLICATION FUR LTCENSE/PERNIIT-20 0 `���
* Please complete form and attach a11 necessa,ry��fine��s� eceinb 15��09� J� 5 .
Failure to do so waill result in the returr�.t�f yc�r��j�hcation pac .t-� m � ;
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NAME OF ESTA�LISHMENT: �G UI �DC� f�,��6,�,� ;;����/,a�d/y TEL. # �D�~39y-a�ya �
LOCATION ADDRESS: i�i6 t3�� �o cK o.d p '
MAILING AADRESS: P,a./�eX '�q1 s0 vT.S/ y,g2i�r�vT�` `y./��y '
O�W�TER NAME: � �T�X ID (FEIN or SSN): !
CORPORATION NAME (IF APPLICABLE): `
MANAGER'S NAME: TEL. #
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Qperator,as required by Stare law. Please list the designated
Paol Operator(s) and attach a copy of the certification to this form. �
1. Q�-�'if,y�`f n�' j��ZS � 2.
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Pool operators must list a minimum o£two employees currently certified in basic water safety,standazd First Aid and
Community Cardiapulmonary Resuscitation(CPR}. Please list these employees below and attach copies o�'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. l I/'�D /�/�U OF �_�T . . . _ _ 4:-
FOOD PROTECTION�IANAGERS - CERTIFICATI�NS:
All food service establishments are required to have at least ane full-time employee who is ccrtified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, I05 CMR 590.000.
Please attach copies of certification to this application. The Health Department wilt not use past years'records.
You must provide new copies and maintain a file at your establishment.
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver an the premises at all times. 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 your place of business.
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RESTAURA.NT SEATING: TOTAL#
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LODGING:
LIC�NSE REQLIIRED �EE PERMIT# LICENSE REQUIRED FE� PERMtT# LICENSE REQUIRED FEE PERMIT#
_,,,_B&B $55 TCABIN $55 _„MOTEL �55
Il�IN $55 �CA1bIl' $55 LSWI1vdMlNGPOOL $80ea. #�0-00
.,_,_LODGE $55 ,_TRAILERPARK $105 ____�„� �WHTRI.POOL $80ea. _
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE It�QUIRED k'�E PERMIT# LICEN3E REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL �35 �NON-PROFIT $30
�>100 SEATS $160 �COMMON VIC. $b0 ,_,_WHOLBSAL£ $80
RETAIL SERVICE: —RESID.KITCHEN �80
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LICENS£REQUIItED FEE PERMTT# LICENSE REQUIRED FEE PE�tMIT# -`� LIC£NSE It��UIRED �'££- �R:�FIT# -_
_<50 sq.ft. S50 >25,000 sq.R. $225 VENDING-FOOD $25
Q5,000 sq.ft. $80 _..FROZEN DESSERT $40 TOBACCO $55
NAME CHANGE: $is AMOUNT DUE = S �p .00
***"*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"*"
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ADMINISTRATION � ` ..
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Under Chapter 152, S�ection 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
AFFIDAVYT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACkIED _ -'
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
i Town of Yarmouth t�es and liens xnust be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
, YES � NO
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, MOTELS AND OTHER LUDGING ESTABLLSHMENTS
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TRANSIENT OCCUPANCY: For purposes of the limitatians of Motel or Hotel use,Transient occupancy shall be
i limited to the temporary and short term occupancy, ardinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place afresidence eLsewhere.
Transient occupancy shall generally refer to continuous occupancy of nat mare than thYrty (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 i,
dwelling unit sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy j
Excise, as defiried in M.G.L. c. 64G or 830 CMR 64G, as amended,shall�enerally b�considered Transiart. I,
POOLS
POOL OPENIrTG:A11 swimming,wading and whirlpools which have been closed for the season must be inspecte�d
by the Health Department�prior to opening. Coz�tact the Health Depaatmerrt to schedule the inspection three(3)tlays
pnor to opening.PLEA.SE N4TE:People aze NOT allowed to sit m the pool area until the pool has been inspected '
and opened.
POOL WATER TESTINGs The water must be tested for pseudomonas,tatal coliform arid standard plate count i
by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly
thereafter.
_ POUL CLOSING:_E_v�_outdoor in ground swimmin�pool must be drained or covereti within seven(7)d�ys af '
closing. . _ __. ---- ------- �
FQOD SERVICE '
CATERING POLICY: ;
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmennt by filing the r
t
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained a�th
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 resu�t in the suspen�sion or revocation of your Frazen 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 ofHealth.
OUTDOOR COOIQNG:
Outdoar cookang,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. �
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NOTICE:Permits run annually from Jattuary 1 to December 31. IT IS YOUR RESPONSIBILT�'Y TO RETURN
TI�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATTONS TO ANY FOOD ESTABLIS1�f1VIENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,ETC.), M[JST BE REPORTED T(3 AND APPROVED BY'1'I-�BOARD OF HEALTH PRIOR '
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
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DATE: `1�-Oq SIGNATURE: V� ;
PRINT NAME&TITLE: 12��,(� /�. Cd�y/�A_ J7zJ%�', QLUh r� ��/G�TS ��, '
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09l25/09
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. The Commonwealth of Massachusetts
Department of Industriat Accidents
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640 Washington Street, 7`h Floor E
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< Boston,Mass. 02111 �
Woricers'Compeasatioa I�urance Atfidavih Bailding/Plambing/Electtical Cootractors �
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