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� .: _ TOWN OF YARMOUTH B4ARD OF HEALT� o
� APPLICATION FUR LTCENSEJ�E " -�010� G3�C�C�M C�D
* *��� � � ,
Please complete form and attach all neces�ary�docu�n�s�y D' et�I�S4�00lA
Fa�lure to do so will result in the retum af your apphcatio
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NAME OF ESTA$LISHMENT: G� � ' � '�L. Sbg 0�3�5
LOCATION ADDRESS: I ' � � ST�2��'� r,�.l o
MAILING ADDRESS: � � I 6
OWNER NAME:�[�c_�4C�t-�i��(�'1��.�BE ���1���l�D���.or.."��.�`T,li O —,�/d38�7
CORPOR.ATION NAME APPLICABLE):
MANAGER'S NAME: CA ' � TEL. # fS SLS
MAILING ADDRESS: < <
POOL CERTIFICATTONS:
The pool sapervisor must be certified as a Pool pperator,as reqnired by State law. Please list the designated
Paol Operator(s)and attach a co�y of the certificarion to tivs form. _ . --- -
1• _���Lr�c-`,i'��.� /�IAS H �'UD�_c_,�;,��t/l. Z.
Pool operators must list a minimwm of two employees currently certified in basic water safety,standard First Aid and
Community Cardiopulmanary 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.
FOOD PROTECTION�VIANAGERS - CERTI�ICATIONS:
All food service establishments are required to have at least Qne 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 wiU not use pRst years'records.
You must pravide new copies and m�intt�in a file at youx estabGshment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours o£operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All foad service e�tablishments witb 2S seats or more must have at least one employee traimed in the Heimlich
Maneuver on the premises at all times. Please list your emraployees trained in anti-choku�g procedures below and
attach copies of employee certificarions to this form. The Health Department will nat use past years' records.
You must provide new copies and ma'tntain a#"ile at you�.place of business.___
1. ,. _ 2.
3. 4.
RESTAURANT SEA'I"ING: TOTAL#
UFF�CE USE ONLY
LOAGING:
LIC�I�TSE REQUIRED FE� PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
TB&B $55 , _CABIN $55 _,MOTEL $55
�INN $55 -� �CAP�II' $55 �;,SW;.'t�IMYT3C'i Pt10�, $80ea. #'��J�
LODGE $55 TRAILBRPARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENS�REQUIRED FEE PERMIT# LIC�NSE REQUIRED F£E PERMIT# LICENSE REQLTIRED FEE PERMIT#
_„_0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 �COMMON VTC. $60 �WHOLESALE $80
RETAIL SERVICE: _ _ . _ —RESID.I{.ITCki�N 580
LIC�NSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# I.ICEIVSE REQLJIRED FEE PERMIT#
<SO sq.ft. �50 >25,000 sq.R. $225 �VENDING-FOOD $25
„_<25,000 sq.ft. $80 _FROZEN DESSERT $40 �TOBACCO �55
NAME CHAI�TGE: $is AMOUNT DUE = $ So�o0
**"*"PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"****
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ADMINISTRATION :� ' "
Under Chapter 152, Section ZSC, Subaection 6,the Town of Yarmauth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not ha.ve a Certificate of Worker's
Compensatian Insurance. THE..ATTACH�D STATE WORKER'S COMPENSAT',ION INSU,RANCE
AFFIDAVIT MUST BE COMPLETED ANII SIGNED, OR , � :
_ _ CERT. OF IlVSURANCE ATTACHED :
Dlt
WORKER'S COMP. AFFIDAVIT SIGNED.AND ATTACHED �
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pennits. �'LEASE CHECK .
APPROPRIATELY IF PAID: /
YES V NO '
- �OTE�.S AND OTH�R�.E3D�IN�EST�4SL�S�ENT� . _ . :. .,
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient 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 tha.t they maintain a principal place of residence�here. '
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)month period. Use of a guest unit as a residence or
dwelling unit sha11 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 general�y be considered Transieat.
POOLS _ .
POUL OPENING:A11 swimming,wading and whirlpools which ha.ve been closed for the season must be inspe,cted
by the Health Department�prior to opening. Contact the Health Departmet�t 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. � _____ ,___��_��..-- -----��-�� �- �.�_ _ ,
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven('l)d�ys af
closing.
FQOD SERVICE
CATERING FOLIC'Y: _ ;
Anyone who caters within the Town of Yarmouth rnust notify the Yarmouth Health Depaitmart by filing the wred
.
Temporary Food Seivice Application form 72 hours prior to the catered event: 'I'liese fornis caii be otitaiu'�t the
Health Department. :,
FROZEN DE3SERTS: _ _ ,
Frozen desserts must be tested on a monthly basis by a State certifi6d lab. Test results must be sent to the Health
Department. Failure ta do so will result in the suspension or revocation of your Frazen Dessert Permit untit 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 ofHe�itb.
OUTDOOR COOI�NG:
Outdoor caoking,preparation,or display of�,ny food praduct b�a r�tail-ccu�ood-serv�ee estab�is�ner�is�rvhibited�-- -- �
NOTICE:Permits run annually from January 1 to Dec�mber 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATIOI�T(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PATrTTING, NEW
EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: ja l o SIGNATURE: �
PRINT NAME&TITLE: CCo �� /3 ��rQ�U,Sz'��
09/25/09
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� t � The Commonwealth of Massachusetts
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Department of Industrial Accideats
�C�/1i1�1�
600 Washington Stree� 7`�Floor
Boston,Mass. 02111
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�I am an empbyer�oviding w�kers'compensation for my employees worlcing on Wis job.
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