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� � '� CA�P�Go�vER S�cnrooD
TOWN OF YARMOUTS BOARD OF HEALTH
� APPLICATION FOR LICENSE/PERNIIT-201�-�, �`` �� - � .
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T Please complete form and attach all necessary�fucu�ie,�ts�b,� 'c�mb���� XS 09 � � �
Failure to do so witl result in the return of yaiir p�Cat pac et. ` � l%;�,:s �
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NAME OF ESTABLISHMENT: Gc� TEL:#�t�`��°,�,'�� F � �
LOCATION ADDRESS: ` p� �
MATLING ADDRESS: f"G.
� OWNER NAME: . n FE or • �,�
° CORPORATION N E (IF APPLICABLE): ,L,�_� ,
MANAGER'S NAME: '�e. TEL. #
MAILING ADDRESS:
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POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Qperatar,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
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Pool operators must list a mmimwm of two employees currently certified in basic water safety,standard First Aid and
Community Cazdiapulmonary 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.
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3• 4.
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FOOD PROTECTION�vIANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
� Protection Mana�er, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
i Please attach copies of certification to this application. The He�lth Department will not use past years'records.
You mast provide new copies and maintain a file at your establishment.
1. 2.
PERSON IN CHARGE:
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Each food establislunent must have at least one Person In Charge (PIC) on site during hours of operation. - -
i 1• 2.
HEIMLICH CERTIFICATIONS:
', All food service establishments with 2S seats or more must have at least one employee traincd in the Hei.mlich
� Maneuver on the premises at all tunes. Please list your employees trained in anti-chok�ng procedu.res below and
� attach cnpies of employee certifications to this form. The Health Department will aot use past years' records.
� You must provide new copies and maintain a�'ile �t your place of business.
1• 2.
3. 4.
RESTAURANT SEA'I"ING: TOTAL#
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4FFICE US� ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIx# LICENSE REQUIRED FEE PERMIT# LICBNS�REQUTRED FEE PERMIT#
,,.,_B&B $55 �CABIN $55 _„_MpTEL $55
1NN $55 �CAIv*,P $55 _,_„SEVIMMtNG POOL �80ea.
�LODGE $55 ,.,_'TR,AII„ERPA,RK $105 _ �WHIRLPOOL $80ea.
FOOD SERVICE:
LICENS�REQUIRED FEE P�TtMIT# LICENSE REQUIRED f�E PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $$5 ______� _CONTINENT,AL $35 NON-PROFIT $30
>100 SEATS $160 yCOMMON VIC. $60 �WHOLESALE $80
RETAII.SERVICE: —RESID.KITCHEN �80
LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED PEE PERMIT#
i<50 sq.R. �SO _>25,000 sq.R. $225 ,_VENDING-FOOD $25
„j,_<25,000 sq.ft. $80 -� r1�0,� �FROZEN DESSERT $40 �TOBACCO $55
NAME CHANGE: $ts AMOUNT DUE = $ so• oa
"**"*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**'"� �
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ADMINISTRATION '
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal. I
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's I
Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMP'LETED AND SIGNED, OR
CERT. OF INSUR.ANCE ATTACHED-
ax
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK
;
APPROPRIt3TELY IF PAID:
YES � NO
MOTELS AND OTHER LUDGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transieirt occupancy shall be
limited to the temporary and shart term occupancy, ordinaril�and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate tha.t they maintain a principal place af residence elsewhere. ;
Transient occupancy sha11 ge�erally refer�to continuou� occupancy of nat more than thirty (30) days, and an .
aggregate of not more than ninety(90) days within any six(6j 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 Transierrt. '
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POOLS '
POOL OPENTNG:All swimnning,wading and whirlpools which have been closed for tlae season must be inspected
by the Health Department�prior to opening. Contact the Health Departmer�t to schedule the inspection thre�e(�)days
prior to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area.until the pool has been uispected
and opened. '
POOL WATER TESTING: The water must be tested for pseudomonas,tatal coliform and standard plate cowrt '
by a State certified lab, and submitted to the Health Department three (3) days prior to openin�, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimmin�pool must be drained or covered within seven(7)days af
closin�.
F40D SERVICE `
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CATERING POLICY: k
.Anyone who catsrs witban the Town of Yarmouth must notify the Yarmouth Health Departmerrt 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. ;
FR.UZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified tab. Test results must be sent to the Health
Department. Failure to do so will result in the suspension or revocation of your Frazen Dessert Pennit untit the
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seatin$with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
_ Outdoor cooking,preparation,or display_of any food product by a retail or food service establishment is prolubited. �
NOTICE:Permits run annually from 7anuary 1 to Dec�mber 31. IT IS YOUR RESPONSIBIL.ITY TO RETURN
TI-iE COMPLETED RENEWAL APPLICATION(S}AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATI4NS TO ANY FOOD ESTABLISHIviENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPOR'TED TO AND APPROVED BY 1'HE BOARD OF HEALTH PRIOR .
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
• �� /� SIGNATURE: ���� '
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PRINT NAME&TITLE: �''��r� v�� ��/-r�'�� � �`�' � �'' /� ��,
09l25/09
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� WOR4C�i2�CdMP�NSAT10h1 AN � �MPiLt�10ERS' �.IABILTY
' IN�URANG�P{�41C° --P-IlVFAi�N1ATION PA��
I P+A�.iGY N�: 4�E480904A
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3 NORFOL� & mBD�M �LTTYTAL FIRL INSURAN�� Cb�'P14NY
22� 7�65 ST�2EE7� RENEWAL
� �EDI�!! MA 0��2� NCCI Compar r No: 21a59
� .��rnportant
� PL�AS�ATTACN THI& AGCOilflt ILQ:
; EI11�C?RSEM�ENT �EtN: �
1 TO�'�UR POb,�'
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�T�IW 9. �NAM�D IN�UFtED�kN[3 MAlLiNG ADQR�SSn AGENT NAM1! :�ND AC1L1f�E�S:
CAPE C�DD33R b'SI�FOOD MARK�T LLC �E�S'GN r °5 �OT,TNG � 37�0�1IdS TI��'
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i �A�2W�C� F O�tT, MP, {32645
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! AE��NT �+1�.: 2(3+�13
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LECsi6►�.EINT!"TY': LI1�II"�SD L�A�3ILITY �t?�dPA�+�'3C �Z�LC�
� OTH��2 WORKPLACE� NnT SHOWlV ABC►V�: (�ee�I�+ric�rs C�rn�ensati�n t;lassifi :ation�ched�ls}
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j IT�M 2. �l�OLICY PERIflD. From: Q1/l�.�a009 1"0: 01/11�2�}�A
� ��ffective 12:p1 A.M. St�ndard Time at tF�� insur�d'�mailir�g ad�r�ess.
ITEIVA�. �CC�3�lEi�AG�:
�. Woricers Compensatit�n Insurance: �art One of tkte policy appii�s to the ifi�r�r��rs C. ars��ensation La�nr of the
,states listed h�re:
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B. Err�sspfayers° Liabifity Insurance: Pa�k Two of th� palicy appiies to w�tie in esch state i1s1 �d an Itern 3.p. The iimits
; of liabiiity e�n�der F�a�k T�va�ar�:
Bodily !r►;ucyr b,y ACCId�Pt�: .� �.I�Q. �0 0 each accident _ _
� g�dwty In�ury Ly nisease: � 500. OAt� p�1ia���'s�it
� t3orlily injury by Disease: $ 3�4}Q r �l10 +Be7C�1 etriplt�y�E
I C. ; Other Siates Ir�surance: P�rt Three+�f thepo ticy appli��t�the stat�s, Ef any, iistec� he��:
j SEE SNDO1t3EML*NT G?'� 2t� C?3 06 �A
D. T�i� �'oficy ir�c4udes th�se Endcarsem,e�ts and Sche�uies:
� S�e Sch�dule ofi Frarms and �ndvrsements.
lTEM 4. , I�REMIUNA: Th�premiur��or•this Policy wil! be deter�rtined by aur�tanuals af Ru6e �, �iass's�i�atiarss, Rate��n�
Ra�ir�g Pir�ns. Ali i�iforma�ion requirer�on the Wcarkers Com�nsation ��assificatio� Schedis4� is sunj��t 4a
v�r�ficai�on�nd char�ge by audit.
' Tc�t�f Estim2�tsd
M'snimum Premeum: $ 2�9 Annt�ai Prem+�m: � 1, 6 5 9
Auclit Periad: A23I�7tJA.L Addit�o��!t Feturn �rern9urr:
Gamrrier�ts :
tssued At: �
Dats: 12/€�3/2 0 0 8 Cat�ntersigned by �
1IN� 00{�+(1�1 A Copy�ight iS87 Na�t�a�al Coun�il ort Carr�pera�ti�ro Insuranc�
�NSURED C4�PV