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� � TOWN OF YARMOUTH BOARD OF HI�ALTH /PN�M ' :
� � APPLICATION FOR LICENSE/PE , ;=�:�0 3� � � �y
� �
�� cXS ���S��F8��3a�.� ��3 �f�f�Q��� �
* Please complete form and attach;all nec�ssai;�y�io��mt�g�by December 1 S 010.
Failure to do so will result��'the f�Yuin o�"your applic�t�on� ' �.-
ESTABLISHMENT NAME: f��lS ��'N/3,�_Prrtrf�'% �'�.� ��� TAX ID:
LOCATION ADDRESS:___ �,3� �'�i�7� �� TEL.#: ;'d�'-�7�'-��fGQ ��:
MAILING ADDRESS: O O
OVVNER NAME: `5 � .
CORPOR�TION NAME (IF APPLICABLE): ��ls/PHrIRyyl,9Gy f�.
MANAGER'S NAME: �'L�-p��„� ,� l�ac,�Asz TEL.#: 56�-77J-G�oS
MAILING ADDRESS: fs fl�ecr-��E ,t�r4�� l,JFs> �itCmot�tl-�, /l��} oa673 !
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator, as required by State law. Please list tlie designated ''
Pool Operator(s) and attach a copy of the cei-tification to this foi7n.
1. 2.
Pool operators must list a minimum of two einployees cui-�ently certified in basic water safety,standard First Aid a�ld ',
Community Cardiopulmonary Resuscitatioii(CPR). Please list these employees belo�v and attach copies of employee
certifications to this form. The Health Department �vill not use past��ears' records. You must provide new
copies and maintain a file at 3�our place of business. �
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments a1e required to have at least one full-tulle employee �vho is certified as a Food
Protection Manager, as defined 'ui the State Sasutary Code for Food Service Establislunents, 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.
L 2.
PERSON IN CHARGE:
Each food establisluiient must have at least one Person In Charge (PIC} on site durui�hours of operation. '
l. 2. ;..,,
HEIMLICH CERTIFICATIONS:
All food seivice establishments with 25 seats or more must have at least one employee trauied ui the Hennlicl� '
Maneuver on the premises at all tinles. Please list your employees trauied in anti-chokui� procedures below and
attach copies of employee certifications to this foi�ni. The Health Department�vill not use past years' records. �
You must provide new copies and maintain a �le at vour place of lausiness. �
i
1. 2. '
3. 4,
RESTAURANT SEATING: TOTAL # '
OFFICE USE ONLY '
LODGI\G: '
LICENSE REQUIRED FEE PERi�1IT?? LICENSE REQUIRED FEE PER��IIT+''- LICENSE REQUIRED FEE PER\�1II'� '
_B&B S55 _CABIN S» _140TEL S��
_INN S55 _CAiVIP S» _S�VIVLv1INGPOOL S80ea.
_LODGE S�5 `TRf1ILERPARK 510� ��VHIRLPOOL S30ea.
FOOD SERVICE:
LICENSE REQL�IRED FEE PER��IIT� LICENSE REQUIRED FEE PER�IIT= LICENSE REQUIRED FEE PER�IIT�
_0-100 SEATS S85 _CONTINENTAL S3� NON-PROFIT S30
_>100 SEATS 5160 _COMMON VIC. S60 �VHOLESALE S80
RETaII.SER�'ICE: —RESID.KITCHEN S80
LICENSE REQUIRED FEE PERVIIT# LICENSE REQUIRED FEE PER�riIT~ LICENSE REQUIRED FEE PER'�IIT�
_<50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD S25
I <2�,000 sq.i3. S30 (—O� _FROZEN DESSERT S40 I TOBACCO S» ����
\Al�IE CHA\GE: S15 AMOUNT DUE _ $ /3SQ0
**�x*PLEASE TtiR\OVER A\D COIIPLETE OTHER SIDE OF FORJ'i"****
f
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ADMINISTRATION
Under Chapter 152, 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. 1'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
�
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
T'own of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES 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. I
�'ransient occupar�cy shall generally refer to continuous occupwncy of nc�t more than tl�irty (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 CNIR 64G, as amended, shall generally be considered Transient.
POOLS !
POOL OPENING: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 De�artment to schedule the inspection three(3)days �
pnor 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. �
POO�,CLOSING: 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 ins�ected by the Health Department prior to opening. Please contact the '
Health Department to schedule the inspection three (3) days prior to opening.
CATERING POLICY•
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by f�ling the required i
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.varmouth.ma.us under Health Department,Downloadable
Fornnc.
FROZEN DES5ERTS:
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 Pernut 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 COOHING: r
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. '
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTl'Y TO RETLJRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIltED FEE(S)BY DECEMBER 1 S, 2010. i
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE:_�/i��/ SIGNATURE:��� � ,�,
PRINT NAME&TITLE: �Sr�� E_ /Vcr��, n7.�sE�
10'06 10 �
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2011•Feb-11 Q3:08 PM CUS 4017703243 2/3
� ' FBb-11-2Qi l �RI 02.15 PM CVS#0735 FAX;5087602585 P.�0 /004
' ?O'WN OE X,A.R11�bU�BOA�tD OF H�4X.x �� '
.��ePraC�,xao�v�oR x�xc�avsrm��r-ao� �3� Z$!k/Y
. *Please compltte fosxia and attach aU�aecaseaty documems b 'er ZOXO.
, . Faii[ure to do so witl rasuit iun tlxc z�fiurn of your a��i + z�paa aet.
�siaB�.Es�NaME:_G►�.� I p�.��.�,rc�v rax in:
LOCA�ONADDRESS; K�R ,Q�u7E � 7ES._�:_�S'd57-77[-� �'J
MA,x�.INCr ADDRIESS' i o �
�WNER NAME:
cox�o��zzorr�r���r���xca�s,���: �s ' c, l
MANAG�R'S NAM�: ��;�0.46.�� � Ncc.�asz. 'FEi...� 568� 71-G 5
M?,,�.JNGADDRESS� y� �'� �
POOL CERTtFxCA�QNS:
Tiie pool super+'fsor must be cGrla�ied as s�oal Oper�tor,as z�qui�red by Sf�a 1R�W. Please list t�c dcs' ted
Foal Q,perAto�{s)and sttaCh a co�y of chc certi�iC.atzpn to tlsis frnm.
1. ���' Z.
�+obl4perators musc lis:a s��t,aium of twoe�p lo ees cwmendy certifiad in basic w��er safesy.sca�idard First P,�ct snd
Com�u,m�ty Ca��diopul�zxona�y�s►,�scitstion{CP�). Flease list theso c�m;ployees b w and attach copios o£ loyee
cert�fficati,ou�tp ttsis f�rm.The Health Department w�i11 z�ot use past��eaxs'r rds. �'ou must pror'rd ne�v
copies and msi�tain a�i1e�t your place�f busineas.
1_ ' N►A- 2.
3. �.
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FdO�PRQ?EC�'�ON�viAN,A,G�RS-C�,RT�FZCATIdNS:
Ail food sGxvxco ostnblisl�ents are required so�ava et�east-oae fi�l-tix�e�mpl e whe�s oestificd as a�ood
Pinteetion Mauager�as de�ud ia rhe St�te 5e�it�uy Code far Food Sorvice�stn ]islune�ts� 145 CMR 39 .000.
Piease a'�ach capics o�'oertification to t�xi�epplicav.c�. 7'he lYe�tla bepartment nai use ps5t years're ords.
Xop u��tp ovide ner+v copies pud mxfnt�i�,a fite at your establ�shmen� I
A�
`1.� p�.��l�Ge�! P�_(�ri.f LT 2 �
P�SON'IN'C'FL4RGE:
�ach food estab3ishnaent m'ust have at lesst one Persan Zn Charge(PTC)on site dwrin�hoeu�s of opeza�L
�. �»h�� � A3o�p�2 z.
HEiMLICH CER'�CATtONS:
A]1 food service est�blisLrnents�v�itb,25 seats ar mqre xnust havE at IeeSt a��e t loye�e t��uned ia the�Ie h
Maneuver on the p�c+�+4�at e�l tfsueg, �1eaSe list your cn, Xoy�ai ttoined in emti I�oki�ng procedures bcla �std
anac�.ccrpies of empioyee cerr�ficat�oz�e to t7�is foim. The�ealt�bepsr�nuent� a,ot use pssc years'r rds.
'K'ou Aau'btprovide,�ew co�ies and maintai�a a�Ic at your�lace oibusiiaess.
1. et�� 2. �
� 4_
R�5TAURAI�'T'S��IVG: TOTAL# a��-- _ � —
O�k�C�CTS�O�Y
LObGL�G:
ZIGk?�75��Qt�k�D FE7E p�RNR7(q I10EN5E ItEQL�ED x�E P1�RMtl R Lt E REQCTIIiED k�£ P£� TT
_g� S55 ,_,,,.,CABIld sss �iOTLT. sss I
3h7v SS� �G.Atv� 555 _S1vt�LvIl1+�G POOL S8ow.�
; �ODOS Sii `TRp�L6RPARK 5145 �V,�R7LpOqi S80w�.�-
FOOD SER�1C£; �
LICYNS'E�QY.�A JF� P7:R.'�Tx LICF1dSE 1t�Q'U11Z�D FEE YFRI9TT R IdC i S6 RSQLIRSD fEE �
0-1�SEATS S80 ,,,,�Cp�'�1�„ 535 �p�'[ S;i, � i
�p10oSEaTS 5360 COA��ltoNj'cC. S6o 'Ti07.�5A7.� SSO �
ttET�.u.SF.Ft�r[CE: Sm_KISC'rIFN 58o i
I.[GT�.NSE REQLTIIte� F�E PER'iMIIT 1Y LICfiNSE REQLIIRF�D FEE PER�A'!y Y.i i 5�Y{EQVIT�A FEE P �P
�a�a.�. sso _;, .�z;,000�.�. sx� nvo_Fao�s�
J,'Q'.�x!-� S� ._,FRQZEt�T DE55�1tT 5�}0 � 08ACC0 S55
�a.1�CH.��B: sts AIY,IQ�INY' �l]E = S�S.�da
�.�rw*P7.IlL5��'CR\O'YF.�t A.\A CO,I�T.E.'Y'I's OTFIERSIIIE OF PO xvr.... �
...._� • ...�.�.� .�-, . , I
2011•Feb•11 03:09 PM CVS 40177Q3243 3/3
� �'Ite Comrnonwealth o�`'Massachusetls
.�epartn�nt of I�dusti ial,,4[ccidents
�ff ce of Ir�vest�'gativns
' X Congress Street,Suit�.�UO
�oston,lt�A 02Yd4-2417
www.mass gov/dia ,
W�xk�rs' Compensatian Ynsurance Af�davit: �ene��Y�usiness�s :
A licant�m�ox�orA,a�n�an ]PIlease P Y�nt]Lae ib
Susin.ess/Organization Name:CVS/pharmacy# �3
A.ddz'ess: Qne CVS Drive, Mail Drop 123Q62A
City/Sta.te/Zip: �Qpnsacket, RI 02895 Phone#: 401-765-1500
tlre you an employer?��eek the appruprfate bo�t: Busine�s 7Cy�e(req�aired):
1.� I atx�.a eznployer with �3 employees(full and/ 5. ❑Retail
or part-tirne}.* 6, ❑RestaurantlBar/Eating�;stablish ent
2.❑ T am a sole proprietor or par�nership and have na �, [] Office and/or Sales(incl.real e te,auta,etc.)
employees working for me in any capacity. g, �Non-profit I
[No workers'comp.insurance requircd] �
3.❑ We are a corporation a�ad its o�ce�rs have exercised 9. ❑Entertainrnent ,
tkxeir x�ght of exemption per c. 152,§1(4), and we ha�ve 1 p Q Manufactut�g '
no em�loyees. [No workers'comp.insursnce requiredJ"' 11.0 Health Care
4.❑ We are a non�profit argauization,staffed by volunfieexs,
wit1�no employo�s. [No warkers' comp.insurance req.] �2•��t�►er
�Any applicant that chscks box#1 must slao ftll out the adcCion below showing their workers'camponsation pvlicy informtdion. I
++Yf the corporats officers have exemptcd themselves,but the eorporation hes othar employees,a worlcers'compens�tion poI3ey is req 'ed end sueh en i
orgenization should check box�/L
d arn an�mployer that isproviding workers'compensallon t'risuranG�for my empLayees. Selow is fhepol� �ttforretatdvn.
Insurance Company Narne: Natianal Union Insurance Company of Pittsburgh, PA
�x�surer's Address: 70 Pine Street �
City/State/Zip: ��w YOrk, NY 9 0270
Policy#or Self ins.�,ic.# �88-05-63 Expiration Date:�1101/24 Z
Attaeh�copy of tb�e woxR�ea�s' compensation policy declaration page(shovvi�g tb�e policy number and pira�aomm c�at .
Failure to secure coverage as roquired u�adex Section 25A of MGL c. 152 can lead ta th�imposition of crimi�al penalties of a
fine up to$1,500.04 atadlor one-year imprisonmcnt,as well as cir+il penalties in the faxxn of a STOP WORTC ORDBR and a ine
af up to$2SU.Q0 a day against the violator. Be ad�+ised that a copy of this statement may be forwarded to th Offtce of
Investigations of the DTA for insurance covc�rage ve�i�icatian.
,�do hereby certify,under the pains and penaltle�of perjrtry that the tnformation provfided above rs true d cD�rect.
Si ature: V' Date: 01 !/
Phone#: 401-765-1500
Off�c�la!use only. Da xo#write an ihis area,to be completed by clty or town off cial
�xty vr�'own: Pernnif/Y,ice�se#
�ssuiu�g.Authority(circle one):
1.Board of Health 2.�ui6ding TAepartment 3. Cityl'�ow�n Clerk 4.Lice�sing Board 5.Selectmen' CDfface
6.�t��r
Co�t�e�Pexson: phone#:
w►vw.mass.gov/aia �