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TOW1V OF YARIVIOUTH BOARD��•�',� �� ��� -�' , hC'�I 14 ��I 1 !
APPLICATION FOR LlCE�iSElPE[ilNL�',=-� i'- ' i
'Please complece form and accsch aU necessary d�m�� � r 2 HEALTH DEPT. 4
Eailure�o do so will result in[he renun of yow applicat�on pac et. i
ESTABLISHMEN'T NA 1 �r'm • s �
LOCATION ADDRESS: • � � 7' L.#:
MAlL1NG ADDR S:
OWNER NAME: err
CORPOItAT10N NAM�IF APPLIC BL :
MANAGER'SNAME: QuIQ '�r TEL.#:77 � CT�
NIAILING ADDRESS:
POOL CERTIFICATIONS_
T6e pooi supervisor must be certitied as s Pool Uperator,,s requircd by 3tate law. Please list the designated Poot
OperatoKs)and attach a copy of the certificadon to th�s form.
1. 2.
P�i operators must list a minimum of two employees cwTentty certified in basic water safety,standard First Aid and
Communiry Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employce
certifications to this form.T6e Heslt6 Departtnent will not uae past years'records.You must provide new copies
and maintain a fde at your place of busiuess. ,
l. 2�
3. 4.
FOOD PROTECTION MANAGERS-CERTIFICATIONS:
Ail food service establishments are required to have at least one fult-time employee who is certifed as a Food
Protectioa Manager,as defined in the State Sanitary Code for Food Service Establishments.105 CMR 590.000. Piease
attach copies of certification to this application. T6e Heslt6 Deparhneat wiil not use past years'records.You must
provide nevr copies and maiatain s file at your establis�ment
1.��-rA,Q.�1 e rr'� 2•
PERSON IN CHARGE:
Each food estabiishmenc must have at least one Person In Charge(PIC)on site during hours of operation.
�. t�o�u.lc� C�se�r-v� z.
HEIMLICH CERTIF[CATIONS:
Ail food service establishments with 25 seats or more must have at 1Past one employee trained in che Heimlich
Maneuver on[he premises at all times. Please list your employees trained in anti-chok�ng procedurcs below and attach
copies of employ'ee ceccifications to chis form. Tbe}leait6 Deparrment wtU eot use past years'reeerds. You must
provide new copies ind maintain a tile at your place of busine9�.
t. Z-
3. 4•
RESTAURANT SEATtNG: TOTAL# D
OFFICE USE ONLY
1�OD(:ING:
LICErSf Rl�]QUfRF.0 FEE PERMIT p LICF�SF REQli1RED FEE VERMIT x LICENSE REQUfRF:U FEE PERMR#
--R9c8 S55 _,�_ _CAB(�i S55 ---_--- —MUTEL S55 . _ _
--I?11V 855 �-- —CAh1P S55 __--�-_ —SWIMMlNGPOOL SROea
_,I.ODC.F 459 . _. _^.TRATI.ERPARK SI05 ________ _WH[RLPt�L 580ea._,___
FOOD 5FRYIC6:
LICEtiSE REQI:tRE� FEE PERMIT# Lll'ENSE RF.QIiIRED FfF. P@RMIt a CICF,NSE RFQUIRED FF,F; PERMIT a
U•�00 SEATS SKS --•_---,-,.- —CO'�TINEn'TAL 535 ___ .___. __YOh-PROFIT 530 __._,_,,.
__�IQOSGTS 5160 ------- _COMMUN VIC. SGO --�,_ ,WHqLfSALE SiSO �_� w�
RETAIL SERVICE: —RESID.KITCHF.�i� � �
LICEVSE REQGIRED FEE PERMIT a IICENSE RF:QUIRFI) FF:E PF.RMIT# LlCE\SE R�pUlRED FEE PPRMiT a
,SO�q ft. 3S0 ___>'_5.0017 sq.ft. 5225 -,_,_ Vf_�DItiG-FOOD S25
,�S,OOQc9.ft. SttO ........__._._. --FRO"!_ENDESSl:RT S40 __ __710RACC0 595 _.___�
�a1►tF.CH��GE: SI5 Ar10UNTDUE = S �V �
**•'•PI.N 1SE TORN UVER ATiD COMP4H7'L'OTHF.R�i1DE OF FORM'*•'• � �� �
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ADNINISTRATION
linder Chapter 152,Section 25C.Subscction 6,the Town of Yartnouth is now required to hold issuance or renewal of j
any license or permit io uperate a business if a person or company does not have a Certificate of Worker's �
Compensation Inswance. THE ATTACHED 5TATE WORKER'5 COMPEhSAT10N INSURANCE �
AFFIDAVIT rtUST BE COMPLETED AI�D SIGrED,OR
i
CERT.OF INSURANCE ATTACHED �
OR
WORKER'S COMP.AFFIDAVlT SIGNED AND ATTACHED '
Town of Yarmouth taxes and liens must be paid prior to rtnewal or issuance of your permits. PLEASE CHECK
APPROPRIA7'ELY iF PAID:
YES NU
VIOTELS MD OTHER LODGING ESTABLISHNENTS
TRANSIEhT OCCL'PANCY: For purposes of the limitations of Motel or Hocel use,Transient occupanty shall be
limited to the temporary and shorc term cecupancy,ordinarily and customarily associated wi[h mocel and hotel use.
Transient occupancs must have and be able to demonstrate that they maintain a principal place of residence elsewhere.
Transient occupancy shall generally refer to contin�w occupancy of not more than thirty(30)days,and an aggregate of
not more ehan ninety(90)days within any six(6)monch period. Use of a guest unit as a residence or dweiling unit shall
not be considered transient, Occupancy that is subject to the collecrion of Room Occupancy Excise,as defined in
M.G.L.c.64G or 830 CMR 64G,as amended,shall gene�ally be considered Transient.
POOLS
POOC,OPENIhG:All swimming,wading and whirlpools which have been closed for the scason must be inspected by
the Health DepaAment prior to opemng. Contact the Health Deparement to schedule the inspection three(3)days prior
to opening. PI,EASE NOTE: People are N07'allowed to sit m the pool area until the pool has been inspected and
opened.
POOL WATER TESTING: 7'he water must be ces[ed for pseudomonas,to[al coliform and standard plate count bya
State certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly[hereafter.
POOL CLOSING:Every uu[door in t;round swimming pool mwt be drained or coverecl within seven(7)cfays uf
closing.
FOOD 5ERVICE
SEASONAL FOOD SERVlCE OPEhIlYG:
All food service establishmenu must be inspected by the}iealth Depar4nent prior to opening. Please contacc the
Heal[h Department to schedule the inspection three(3)days prior to opemnb.
CATERIIVG POLICY:
Anyune who caters within the Tovm of Yatmouth must notify the Yarmouth Health Depar4nent by ftling the required
Temporary Food Service Applicatian form 72 hours prior w the catered event. These fortns can be obtamed at the
Health Department,or from the Town's website at www.yannouth.ma.us under Health Deparanenc,Downloadable
Fortns.
FRU'LEN 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 cfo so will result in the suspens�on or revocatiun of your Froun Dessert
Permit until the above tertns have been me[.
OUTSIDE CAF�S:
nutside cafes(i.c.,outdoor seating with waiter/waitress service),must have prior approval fi•om the Board of Heald�.
OUTDOOR COOICING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohtbited.
�OTICE:Perrrtits run annually from lanuary I co December 3I. IT IS YOUR ItE5POfVSIBILITY TO ItETURN
TH�COMPLETED RENEWAL APPLICAT[ON(S)AND REQUtRED FEE(S)BY DECEMHER I S,2010.
ALL REVOVAT[ONS TO ANY FOOD ESTABLISHMENT, MOTEL O[t POOL (i.c.. PAINTING, NEW
EQUIPMENT,ETC.).MUST BE REPORTED TO AND APPROVED BY THE BUARD OF HEALTH PRiUR TO
COMME�ICEMENT. RENOVATIONS ytAY RE IRE A (TE P N.
DATE: 1 II S[GNATURE: F�-
PR[NT NAME&TITLE:__,, I Y — r
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�`� The Cowrmonwtaltb ojMas�achusetts
Depart�reat ojlwdrrsrrial Accidentir '
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600 Was6iegtow Sdet� ��Floor '
Bo�rr,Ma�s. 011l!
Wori[ess'Coape�sstioa f�svaac�e ARid�vit:B�itaia6/Pl��bis�/Eketritai CoshYctors
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