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TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT-2017
�`Please complete form and attach all necessary documents by �ember 6 2(J : .
Failun to do so will result in the return of your applicshon pac cet.
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, ESTABLISHMENT NANfE:
LOCATfON ADDR.ESS; I►G Vl T'EL.#: � � �
MAILING ADDRESS: A- 4
' E-MAIL ADDRESS:
OWNER NAME:
CORFORATION NAME(IF APPLICABLE): YYl L C�
MANAGER'S NAME: � y► TEL.#: -
MAILING ADDRESS: G wv ri S ut7�1rt
POOL CERTIFICATIONS:
The pool superviaor mast be certified as a Pool Uperator,as reqnired by State taw. Please list the designated
Pool Operator(s)and attach a copy of the certificadon to tlus fortn.
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Pool operators must list a minimum Qf two employees ewrent(y certified in standard First Aid and Community -�-I rv � �'�
Cardiopulmonary Rcsuscitation(CPR),having one ceRified employce on premises at all times. Please list the 2 c,u E �
employees below and attach copies of their cemfications to this farm.T6e Health Department will not use past �? �,�, g, �
yesra'recorda. Yom m�at provide new copies and m�intain�!lle at yoar place of business. � c, � �
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FOOD PROTECTTON MANAGERS-CERTIFICATIONS: �, ��
All food s�rvice establishments are required to have at least one fuil-rime employee who is certified as a Food � '�=
Protaction Managcr,as defined in the State Sanitary Code tbr Food Service Establishments, 105 CMR 590.000. ` '
Please attach copies of certification to this application. TLe HeaiNt Departmeat will not use past years'records. `
You must provide ne�v copiea and maint�in a#ile st your establishment. 4 '�''
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PERSON IN CHARGE: �'
Eech food establishment must have at leest one Peison In Charge(PIC)on site during hours of operation. � =G-
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ALLERCiEN CERTIFICATTONS:
Ali food service establishments are required to have at least one full-time employee who has Allergen certification,
? as defined in the State Sanitary Code for Food Service Establishments,105 CMR 59Q.009(G)(3)(a). Please attsch �
copies of certification to this application. The Hexlth Department will not use past ycars'recorda. You must �
provide new copies and maintain a file at yonr establishment. T
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HEIMLICH CER'TIFICA"1TONS: �
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich .J
Maneuver un the premises at all times. Please list your employees trained in anti-choku►g procedures below and
attach capies af employee certifications to this form. T6e Heslth Dep�rtment wil!not use past years'recards. �
You must provide new copica xnd maintaxi a file at your place o�basinc,as. (�
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RESTAURANT SEATIIVG: TOTAL# d ��
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z.,oDGnvG: OFFICE USE ONLY
LICENSE REQUiREp FEE PERMIT ll LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT q
a8c8 S3S CABIN S55 _MOTEL 5114
1NN SSS =CAMP SSS _SWIMMING POOL S110ea
_I,OD(3E S55 TRAII,ER PARK SI05 _WHIRLPOOL S110ee.
. FOOD 9ERVICE:
LICENSE RE FEE PERMIT# LlCENSE REQUIRED FEE PERMIT q LICENSE REQUIRED FEE PERMIT#
0-1D0 SEAQI'�S�D 5123 �p C4NTiNENfAL t35 NON-PROFTf S30
�.t �>100 SEATS 5200 �s�CJ _I-_CAMI�'10N VIC. S60 �-Z.rj —1VHOLESALE S80
xcr�L s�Rvrc�:
—�sm.icrrcc�aso
LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_Qg•s4-ft. S30 >25,000 ft. 5285 VENDING-FOOD S23
OOO sq.R S1S0 �ROZEN�ESSERT S40 �i'OBACCO 5110
NAMECHANGE: Si5 AMOUNT DUE _�� �� � �
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k•t""*pLEASE TURN OVBR A,ND COMPI.ETE OTHER SIDE OF FORM►*r�r
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ADMIMSTRATION
Under Chapter 152,Scctioa 25C,Sub�°:ction 6,tt�Town of Yarmouxh is�w roquired to hotd isguance or m.aewal
of aay license or permit to operabe a bnsiness if a pea�son or wmpany dces not have a Cezfi��icate of Worker's
� Compensatian lnsu¢ance. THE ATTACAEII �'I'ATE WORKER'S COMYENSATIOlY INSURANCE
'; AFFIDAVTT MUST BE CUMPLETED AND SIGNEA,OR � •
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� CIItT,OF INSURAAICE ATTACHED
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; WORKE.R'S COMP.AFFIDAVTf SIGNED AND ATTAC�IED
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Town of Yarmouth taxes and tiens must be paid prior to renewal or issuance of your pe�mits. PLEASE CHECK
A,PPROPRL4TELY IF PAID: %
XES l`� NO
MOTELS A1�ID OTHER Lt3DGIlYG ESTABI.ISI�MENTS
TRANS�EN'T OCCLTI'ANCY: For gucgoses of the limitations of Motel or Hotel use,Tiansi�►t occupancy shall be
limited m the temporary and short teim oocul�ancY,ordinarily and customarily associsted with moteI and hobel use.
; Tz'ansient occupants must have and be able to demonstrate that they mainl�ain a�incipat place of reside�ce
; elsewhere.Transient occupancy shall generally refer to continuous occupancy ofnot more than thuty(30)days,�nd
an aggc�egate ofnot more than ninety(90)days wit�in any siac(b)month period. Use ofa guest unit as a residence or
� dwelling unit shatl�t be considered tcansient. Occupancy that is subject to the c�llection of Roou►Oc�upancy
i Excise,as defi�ed in M.(3.L.c.b4Cr or 830 CMR 6�G,as amendsd,shall generally be cor�sidered Traosieat
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POOL OPENIlVG:AIl swimmi�n$,wadiag and whirlpooIs which have bee�cic�ed fort�season must be inspected
by the Health Departrnent to Contact the Health ent to as�edule�+e n three(3}
�yins�ted and o�����Peaple are NOT allo��i in the pool ac�um���1 has been
POOL WATER TESTING: The water must be tested for pseu�monas,total cotiform and standari glate couat
bthe�er.certified lab,and submitted to the Health I�partment three(3)days prior to opening,and quarterly
' POOL CLOSING:Every outdoor in gra�nd swimming pool must be dcained or covexed wiihin seven(�days of
closing.
' FOOD SERVICE
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' SEASUNAL FOOD SLRVICE OPENING:
' A!1 food service establishm�ts must be inspect�by the Health llepettnnent prior to apening. Please�ntact the
Heatth Departmeat to schedate thc inspection th�ee(3)days prior to opening.
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' CATERING PU�ICY: �
; P►uyone who caters within the Town af Yarmouth must notify the Yarm�►rth Heaith De,partmeia�t by filing tbe
� required Temporary Food Service Application form 72 hoars prior to the c�tersd ev�t. 1liese forms c�.n be
, obtaineri at the Health Dep�rtment,or fr+nm the Town's wehsite at www yarmouih.mau$unckr Health DeparGu►ern,
Downloadabie Fornas,
FROZEN DESSERTS:
Frozen desserts m�st be tested by a State certified lab prior to openiag and monthiy thereafter,with sacnpte results
submitted to the Health Department Faitnre to da so will r+�utt iun the snspensian or re,wocation of your Frozen
Dessert Peimit until the above tetms have been met,
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/vvaitress service),must have gri�approvai fi+om tbe Board of Heaith.
OUTDOQR COOKING:
�utdoor cookin8.PnP���r displaq of atry food product hy a netail or food service estabiishment is pro6ibitred.
NOTICE:P�nits nm annually fr+om January i ta D�ece�mber 31.IT LS YOURRE3POIV`SIBILITY TO RETURN
'THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ET'C.),MUST BE REPORT ED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR -
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PL.AN.
DATE• j!` ,��I � SIGNATURE: � ���f ,
PRIlVTNAME 8t TTTLE'—�t� n�Y �� �3f�'v�� � /� !✓1a 4��
�.iaizr►e . .
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'`��-'�'�'� GERTIFICATE OF LIA�IL.tTY iNSURANC� �"'�`"'�""
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THI.S CERTIFlCAT� !,S ISSt1ED AS A MATTER AF INFQRMATION QNl�1f AND CONFERS N�RfGHi'S GPQN THE CERTtFlCATE HQLDER.Tt#!S
CERTIFlCA7E �3 NC?T AFFIRMATiVEI.Y OR NEGATlV�Y AAA�, E)CiENR OR A1,l�R THE C01/ERAG� AFFORDED 8Y THE POLIClES
�OW. THIS GERTIFICATE OF INSURANCE I�UES NOT CONSTlTU'f� A GONTRAC3 8E1'WF�PI THE ISSUING (NStniER(9). AUTHORI�3
RERRESENTAT{VE OR PRODUCER,AN�THE CERTIFlCATE HOLDER
NNPORTANT: 1i lf�e certificatie lyd+der is an AODRiONAI. IMSURED.the policy(ies}must be endorsed. if StlBitQ�A'flOM IS WAiVED,subject to
the terms and conditlons of the poticy.certa�poticiss r�y requine an erntcxse�G A stat�ent on this ceniticate daes not confer rights ta tbe
c+ertificaber hotder in lisu of such s.
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C�YERACaES CERTtFIGATE NUiI�BER: REViSlW+1 NIiN�ER:
THIS IS.TO CERTi�Y Ti1AT THE POUCIES OF MStlRANCE USTED BELOVY HAVE BEEN tSSUED TO THE INSUREQ MAMED A@QVE F0�2 THE PQUCY PER�
INDICATED. NOTWITHSTANDING ANY RfQU1RE#�tENT,7ERM OR GONDITFON OF ANY CONTRACT OR OTHER DOGUMENT W�TN RESPECT TO WHICN TFq3
CERTIFlCA'TE MAY BE ISSUED OR MAY P�RTANt,TFlE INStlRANCE AFFORDED BY THE POLICIES DESCR{BED HEREIM IS SUBJECT Tfl ALt THE TERMS,
EXCLUSfONS AND COf�lORtO(VS OF SUGH POUCIES.UMRTS SHpWfd iNAY FtAVE BEEN REDUCED 8Y PAiD CtAIMS.
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CERT�FiCAT�HOIQER CANCELLATlON
YARIi�OUT
�l�NY�'ThE nF3ovE o�SCR�ED PO�.iCiES s�cMtc�LLEo sEFORE
Town of Yarniouth '� Ex�atroa �a� �oF. t�ro� tanu. eE oE��REn �
ACCORQANCE YYITH 7HE PQLICY PROVISIaVS.
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