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� ► TOWN OF YARMOUTH BOARD OF HEALTH �� .
,' � � APPLICATION FOR LICENSE/PF.�tNIIT - 0 2'`� �
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* Please complete form and attach all necessary doc en s hb� y e ` r IS 2011.
Failure to do so will result in the return of your appl�ication p e EPT,
ESTABLISHMENT NAME: `i�`�n..c�3 4- �� ��c� L TAX ID;
LOCATION ADDRESS: �'�� �"'�-'4-�-�-S7' W• y��---'�i TEL.#: �'a�" � 71 'Gf""
MAII.ING ADDRESS: �-�
OWNER NAME: :.L- `� ��� �-�' }�Z��
CORPORATION NAME(IF APPLICABLE): S��-�-�`
MANAGER'S NAME: t'j��LC- �y -�-�s TEL.#: 5�� 3g y y 23�
MAII.ING ADDRESS: s�-�c '
POOL CERTIFICATIONS:
The pool supervisor arust be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of e certification to is form.
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Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary 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�le at your place of business.
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3. ��.r, ;� 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 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.
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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: j
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 times. Please list your employees 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�le at your place of business. �
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RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY '
LODGING: '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 I MOT'EL $55 /o�-'� ;6 '
_INN $55 _CAMP $55 �-SWIMMING POOL $SOea. ��%a�G� ',
_LODGE $55 _TRAILER PARK $105 I WHIRLPOOL $80ea ��a a"? '
FOOD SERVICE: �
_ _-- _ _ - - --— -- —--- �
------ ____-_-_________-- _---- ._ __- -- --- - -
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $85 �(�?J'� _CONTINENTAL $35 _NON-PROFIT $30
_>100 SEATS $160 � COMMON VIC. $60 ia�8� _wHo�s� $80
RETAIL SERVICE: , —RESID.KITCHEN $80 '
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25
_<2,5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: �is AMOUNT DUE _ ���O��O ;
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*****PLEASE 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
of any license or permit to operate a business if a person or company does not have a Certi�cate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED 8e{"�-�,-�'�
. OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED '
Town 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
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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 i
elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and j
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 CNIl2 64G, as amended, shall generally be considered Transient.
POOLS
POOL OPEI�IING: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 Department to schedule the inspection three(3)days
prior to opening.PLEASE NOTE:People are NOT allowed to sit in 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.
POOL 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 inspected 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 filing the
required 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.yarmouth.ma.us under Health Department,
Downloadable Forms. �
FROZEN DESSERTS: !
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results j
submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen ;
Dessert Permit until the above terms have been met. '
, i
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. '
OUTDOOR COOKING: '
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited.
_ ._ --a
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NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED N"EE(S)BY DECEMBER 15, 201 l.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW �I
EQUIPMENT,ETC.),MUST BE REFORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ,
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I
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DATE: I �>�/�� SIGNATURE: ' , ',
PRINT NAME&TITLE: � ��h� ����rs l�� I,,
Rev.10/25/11
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. `�'� The Commonwealth of Massachusetts
Department of Industrial Accidents
N�INiw�M�
600 Washington Street,�7`�'Floor
Boston,Mass. 02111
Workers'Compeessitioa t�arance AtRdavth
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work site location(full addressl:
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity.
[�I�am an employer providing wa�kkecs'compensation fa�my employees wodcing on Wis job. '
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❑ I am a sole proprietor,geaeral co.tracMr,or iomeowaer(circJe nw�)and have tured the contractas listed below�who^have
the following workers'compensation polices:
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