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TOWN OF YARMOUTH BOARD OF HEALT$ �����j`�' '
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APPLICATION F4R LTCEl�E/.�T.R�"��UfO
Please com lete form and attach all� "� 3Q
* P +�e�ssa�r5'c�t�c��Dec mb�f,T5�2b09. �
Fail.ure to do sa witl result in tli�;;�tu��af'�our apphcation a �q�I H utr � .
NAME OF ESTA�LISHMENT: � TEL. #3 -� � �� �
LOCATION ADDRESS:\
MAILING AI�D S S'— •- l Z D d
OWNER NA1vIE: D FE or ��' ;
CORPORATION NAME (IF APP ICABLE). c..�
MANAGER'S NAME: TEL. # � Q��'
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool sapervisor must be certified as a Pool Qperator,as required by State law. Please list the designated
Po_ol Operator(s) and attach a copy of the certificarion to this form.
_ __.
1. 2. '
Pool operators must list a minimum o£two employees currently certified in basic water safety,standard Fiarst Aid and
Community Cardiapulmonary Resuscitation(CPR}. Please list these employees below and atta.ch copies of employee
certifications to this form. The Health Department wi11 not use past years' records. You must provide new
copies and maintafn a fi1e at your place of business.
1. 2.
3. 4.
�(00D PROTECTION�vIANAGERS - CERTiFICATIONS:
All food servic� establishments are required to have at least one full-time employee who is certified as a Food
Protcction Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this applicatian. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
1. 2.
PERSON I1�T GHARGE:
Each faod esta�ishmenf musf have at least one I�erson`In�,Tiarge�'1�jori siteaurm-'�ours o operation.— -
1. 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 rimes. Please list your enp loyees 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. - .
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1. 2. ' . .
3. _ , 4.
;
RESTAURANT SEAT"ING: TOTAL#
OFF'�CE USE ONLY
LODGING:
LIC�NSE REQITIRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT#
_,B&B $55 _CABIN $55 �MOTEL $55
lI�lI�1 �55 _ �CAMP $55 �SWIMMiNG POOL $80ea.
�.ODGE $55 �'TRAILBRPARK $105 ____WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P$RMTT# LICENSE REQUIR�D �£E PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $85 ._CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 COMMON VIC. $60 WHOLESALE $80
RETAII.SERVICE: —RESID.KITCHEN �80
_ . __ _
LICENSE REQUIItED fiEE PERMTI'# LICENSE REQUIRED FEE PERMI'T# I,ICEN�E REQUIR£D FEE PER1viIT'# ;
_ .._ ... _ . _ ..
,.,. �....
�<50 sq.it. �50 >25,000 sq.ft. �225 �VENDING-FOOD $25
�<25,000 sq.ft._ $80 (C)--O �FROZEN DESSERT $40 �TOBACCO $55 �0��
NAME CHANGE: $is AMOUNT DUE = S: /s�S.n�
*w"**�'L�ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"*"
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ADMiNISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal
of any license ar pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WOR.KER'S COMPENSATION Il�TSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR -
CERT. OF INSURANCE ATTACHED __ _..___ _ _
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CI�CK
APPROPRIATELY IF PAID: I
XES NO �
MOTELS AND OTHER LODGING ESTABLISHMEN'�S _ , '
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transiern occupancy shall be
limited to the temporary and short term occupancy, ordinaril�and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a prinapal place af residence�isewhere.
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)manth periad. 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, sha11 generally be considered Transient.
_ POOLS
POQL OPENING: .All swimming,wading and whirlpools which ha.ve been closed for the season must be ins
by the Health Department�priar to opening. Conta.ct the Health Department to schedule the inspection three(�
pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area.until the pool has been inspected �
and opened.
PUOL WATER TESTIl�TG: The water must be tested for pseudvmonas,total cnliform and standard plate count �
by a State certified lab, and submitted to the Health Department three (3) d�ys prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)d�ys of �
clos�ng.
FOOD SERVICE
CATERING PQLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme,nt by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. Th�se forms can be obtained at the �
Health Department.
I
FRUZENDESSERTS: -- - �
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 result in the suspension 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 COOKING: i
Outdoor caoking,prepararion,or display of any food product by a retail ar food service establishmern_is�rohibited. __ __ �
�
NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RE5PONSIBILIT'Y TO RETURN
THE COMPLETED RENEWAL APPLICATI4N(S)AND REQUIltED FEE(S)BY DECEMBER 15, 2009.
I
ALL RENOVATIONS TO ANY FOOD ESTABLIS�:[MENT, MOTEL OR POOI. (i.e., P.A,IN7CING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY 1'HE BOARD OF HEALTH PRIOR
TO GOMMENCEMENT: RENOVATIONS MAY REQUTRE A SITE PLAN.
., . ,
DATE: . . � � �� B SIGNATURE:
PRINT NAME&TITLE: i
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o9�zs�oa Tax Manager i
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_—=_� The Commonweatth ofMassaclztcsetts
� Depaf-trnent oflndust�-ial Accidercts
� — 0ffice nf/na�estigations
_ _ < 600 Washington Street, 7`h Floor
�� �' Bostorz,Mass. 021I1
Workers'Com ensation Insurance Affidavit-General Businesses
name• IN
address: 100 CROSSING BOULEVARD
c; FRAMINGHAM MA 01702 (508)270-1400
state: zi : hone#
work site]ocation(full addressl•
(_] I am a sole propnetor and have no one Bnsiness Type: �Retail Q RestaurantBar/Eating Establishment
working in any capacity.
�I am an em lo er with 6��9 ❑Office Q Sales(including ReaI Estate,Autos etc.)
Y �m loyees(fuil& art time). ❑p�er
I am an emplo er providing work 'compensation for my�empioyees working on this jo�.
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❑ I am a sole proprietor and have hired the independent contractors listed below who have the following workers'
compensation polices: _ :
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Failure to secure coverage as required under Section 25A ofMGL 152 can lead to the imposition of crimina[penaltiea of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OfiSce of lnv ' ations of the DIA for coverage verification. '
I do hereby certify under the �s a d pe `!ti ofp u at the information provided above is irue and cor ect. �
SigiaNre c� ;
Date __ t p� 01 � Q � i
Printname RICHARD FOURNIE � j
Phone# �508)270-1400 �
officiai use only do not write in thSs area to be completed by cfry or town ofiictal
cfty or town: permit/license# '
OBuilding Department
❑check if immediate response is required �Licensing$oard '
�Selectmen's Oifice
contact person• phone#; �Neatth Department
' (m�eas��2oo3) ❑Other
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