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„ � TOWN OF YARMOUTH B4ARD OF HEAL� �ri .
AP'PLICAITON FOR LTCENSE/PER11�.'T�?�I�Q,, � �
�.� �y� $ x �� � �`a MAR fi 'i � ��:,�
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*Please complete form and attach all necessary doc�lent ' ecembe Y �h uti= i .
Failure to do so will result in the return af your application pac
NAME OF ESTA�LISHMENT: (LA'C, ��I I��'� S TEL. # ���7 I S�I Z-
LOCATION ADDRESS: b �lT T f t'�tQ�'N
MAILING ADDRESS: �" s►�M�-
OWNER Nt�ME: 'L�S YYtl.c,�1 FE or • � '
CORPORATION NAME (IF APPLICABLE): " L-
MANAGER'S NAME: ��-�R-�S l�lV�l��r� TEL. # s�0 a3 7L
MAILING ADDRESS: �--'� ��ML' --
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to xhis form.
l. 2.
Pool operators must list a minimwm o£two employees currently certified in basic water safety,standard First A.id and
Community Cardiapulmonary Resuscitation(CPR). Please list these employees below and attac�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 yonr place of business.
l. 2.
3. 4.
FOOD PROTECTION�vIANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least ane 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 Heatth Department will not use past years'records.
You must provide new copies and maintain a file at your estRblishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Persoz�In Charge (PIC) on site durin�hours of operation.
l. 2•
HEIMLICH CERTIFICATIONS:
All food service establishwents with 2S seats or more must have at least ane employee trained in the Heirnlich
Maneuver on the premises at all tumes. Please list your employees trained in anti-chaking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
Yau must provide new copies and maintain a ffle at your place of basiness.
1. 2.
3. 4.
RESTAURANT 5EAZ"ING: TOTAL#
OFF�CE USE ONLY
LODGING:
LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 ,rCABIN $55 _,,,MOTEL $55
rINN $SS __,_CAMP $55 _,_SWIMMCNG POOL $80ea.
�LODGE $55 �TRAILERPA.RIC $105 �WHIRLPOOL $80ea.
FOOD SERVICE:
LICENS�REQUIRED FEE PERMIT# LIC£NSE REQUIRED f�E PERMTT# LICENSE REQUIRED FEE PERMIT#
0-100 SBATS $85 ,—CONTINEN'I'AL $35 NON-PROF'IT $30
'I �>100 SEATS $160 �COMMON VIC. $b0 ____WHOLESAL� $80
RETAIL SER'�ICE: —RE3ID.KITCHEN S80
LIGENSE ItEQUIRED FFsE/ PE #d�3 LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT#
� �<50 s .R. � �'_���C�tr >25,000 sq.ft. $225 VENDING-FOOD $25
q � .�
! �,25,000 sq.ft. $$0 _FROZEN DESSERT $40 �_ ,,,_TOBACCO �55�
, AMOUNT DUE _ � �� r
' NAME CHANGE: S 15
� **""*�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*""**
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ADIVIINISTRATION T `
Under Chapter 152, Sectaion 25C, Subsection 6,the Tawn ofYarmouth 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 Certifica.te of Worker's
Compensaxion Insurance. THE ATTACH�D STATE WORKER'S COMPENSATION INSUItA,NGE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR /
WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED "�
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yaur pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LQDGTNG ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limita.tions of Motel or Hotel use,Transieirt occupancy shall be
limited to the temporary and short term occupancy, ordxnarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demanstrate that they mairnain a principal place afresidence elsewhere.
Transient occupancy sha11 generally refer to continuous occupancy of not more than t�rty (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 sha11 not be considered transient. Occupancy that is subject to the collectian of Raom Occupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transiart.
POOLS
PUOL OPENING: .All swimming,wading and whirlpools which have been closed for the season must be insp��
by the Health Department prior to opening. Contact the Health Departmertt to schedule the inspection three(�)days
pnor to opening.PLEASE NOT�.People are NOT allowed to sit in the pool area until the poot has been inspected
and opened. ,
POOL WATER TESTING: The water must be tested for pseudomonas,tatal coliform and standazd plate count �I
by a State certified lab, and submitted to the Health Department three (3) days prior to opendn�, and quarterly I
thereafter.
POOL CLOSING: Every outdoor in ground swimming paol must be drained or covered within seven(7)d�ys of �
closing.
F40D SERVICE
CATER.ING POLICY• j
Anyone who caters wit}ain the Town of Yarmouth must notify the Yarmouth Health Department the
Tempora.ry Food Service Application form 72 hours prior to the catered event. These forms canbe�obtaiuied a�th
Health Department.
f
FROZEN DESSERTS: �
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 o�your Frozen Dessert Permit until the �
above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoar seating with waater/waitress sernice),must have prior approval from the Board ofHealth. '
OUTDOOR COOKING:
�
Outdoor cooking,preparation,or display of any food product by a retail ar food service establishmern is prohibited.
NUTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RE'T[JRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATIONS TO ANY FOOD ESTABLISEf1VIENT, M4TEL OR POOI. (i.e., PAINTING, NEW '
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�E BOARD OF HEALTH pRIpR i
TO COMMENCEMENT. RENOVATIONS MAY R.EQLTYRE A SITE PLAN. f
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DATE: ��(�(,-� l$T Zn 1 t� SIGNATURE: ' � i
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PRINT NAME&TITLE: � h�`lS�p1�e.('.�,� h\�(yt�,�.((� ;
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09/25/09
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��" �\ The Commonwealth of Massachusetts
Department of Industrial AcciJents
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600 Washington Street, 7`�'F[oor
Boston,Mass. 02111
Worlcers'CompeAsation Iosorance AtS�v#:B�ilding/Plambieg/Electrical Contractors
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name: ��Yl S��-'( ��(1,Y�C'��
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work site location ffiill addnssl_ `
�am a homeowner performing all work myself. Project Type: ❑New Conshnction QRemodel
I am a sole proprietor and have no one working in any capacity. Q Building Addition
❑ I am an employer p�oviding warkexs'compensati�for my employees worlcing on this job.
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We following workers'compensation polices:
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