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TUwN UF YARMUt1TH BOAR13 OC HEALTH
APPLIrCATiQN FUR L3CENSEt�'�RMIT-2{Il'7
*Ple,ase ccs�nplGcc form a�uc#att�h a�l��dc�umen�s by .cl��er,,�b.3(Ji�. �
Failure to do�witI sesult in the return of yv�u Bpplir.�on pac cet, i
ESTABLISHM�ItitT N : i r � � ,
LOCATTON AUDR�SS: F �' ,. �+y. �. � i
MAILING ADURES : , t' vt � � i
E-MAIL A.D� S: ,,n , �
QWNER IVAME: �' ,'tt r l O
cax�o�.a�vrr�v�� ��.rc r.�}: � ;
MANAGER'S NAME; �n TEL.#: -
MAIL]NG ADDRESSr , � �
PQ4L CERTIFTCAT[OI�IS;
Tbe pont snperv�ur�nst be certitkd�s a Poot flperater,as re�luired by State law. Please iist thc designa i
Poot 4perator{sl ar�ci attach a�opy aFthe certificatioc►ta t�is form. �
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Pool o �' c �`�.�� ��
persiocs must t�st a minimum of two employees currenily certifi�i in sKanclard First Aid and Comrnuni, .� N ��
�rd�ogulmonety Resuscitation{Ci'R�,having one certiCzeE#em_ployee an_�prernises at alE timcs. Ftease list -� �, ;;�
e�►PloYcts below arial attach cc�pies af tl�eir certifications to this form.T6c Nealth t vvi,U aot nae � :� ,
Ytara't�ards. Yon mast ptovide naw ropi�es aud maiataia a;fik af yoar p l i i t c c at besi�a, �� o ��,
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��n�xo�c�nQrr�x����s-c�r���c�.riar►s:
A!I fcwd servic;e est�lishments are rcquircd ta havc at lesst one fult-time emp)Qyee w}�o is cexti�ed as a Food
Protection Manager,as de�ned in the Ssate Sanita�y�ade far Fctod Service Estabti�s, t0S CMR S90.fklQ.
Pfease attxch copies oFt�rtificarion to this�pplic.etion. The H�ti6 l?epsirtmeat rrilt nW use '
Yau mnat gnuvide nc�r capks s�d�latun�!ik�rt yaur estabti�i►me�t, P�Y'�a�'r�rds. -�.,�,
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FERS(3N IN CHARGE; I
Each fc�od estabf' must hsve at least one Pcrson In Charg��ptG),an sitc during}�urs of operatian. � ,
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ALLERGEh1 CERTiFTCATiONS: �p '
A!I fcxtd servicx establis6tuents are c,cquirc.ct to lrave at ieast anc fiill-time em o Z'�
as deiir�cl in the Stat�Sani Code for Foad Scrv�ce Estabtishments IU5 CM14 5�°has Atlergcn c+:rtification, � !
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copies uf cettificatiaa ta this appiication. T!►a Iic.�itft llepArtmeut w#il aot�ae Fas#y�srs'recoMa. You��t �
' e ns�v c»pi� d�ainiais a ffk At your sstabl��ment� �
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HEIML.ICH CERT7FICATIt}NS:
Ali food ser+rice e�tabiisbments with 25 seats ar mare must have at least one em i
Maneuver an the premi�s at alt times. P1es�e li� our em la P�trained ia the Heizntich
atiach co ' c�F�n � Y P �es trained in aari-ct►aking prcxxduces belaw a�ui
� Pt Y�certific�6ons to this firrm. Thc Hcs Dr�trt�e�rt wlil'�at a�r,e �u
Yoa most provide cop�s sad ms�t�Le n fik:t yoar ptace af bas#mass. P+�}'�rs'records.
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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. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED ✓
OR
WORKER'S COMP.AFPIDAVIT SIGNED AND ATTACHE
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� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
j YES_� NO
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� MOTELS AND OTHER LODGING ESTABLISHMENTS
� TRANSIENT OCCUPANCY: For pwposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinazily and customarily associated wittt motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.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 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 CMR 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 Department to schedule the inspection three(3)
days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool azea until the pool has been
inspected and opened.
POOL WAT�R 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 swimxnir.g pool must be drained or covered within seven(7)days of �
closing. ,
FOOD SERVICE V
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 Yannouth Health Department by filing the
required Temporary Food Service Apptication 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 Forms.
FROZEN DESSERTS: :
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 Permit until the above tenns have been met. '
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOHING: ;
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
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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 FEE(S)BY DECEMBER 16,2016.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
' EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE�OARD OF HEALTH PRIOR �
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE I ' �"' , ;
' DATE: � �I I 6 SIGNATURE: � ' !
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PRINT NAME&TITLE: ; �tI I' � I 6 (� �
Rev.10/1?!16
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� The Commonwealth of Massachusetts
Department of Industrial Accidents
O�ce of Investigations
' 1 Co�gress Street, Suite 100
i Boston,MA 02114-2017
' www.mass.gov/dia
Warkers' Compensation Insurance Affidavit: General Businesses
A licant Information Please Print Le 'bl
Business/Organization Name: �� � � ( p I i L, G 't� �� -� �i�T
Address: i' � o�
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City/StatelZip: `� ��' � �� � Phone #: � Q�
� Are you an emptoyer?Check he appropriate boz: Business Type(reqnired):
� 1.� I am a employer with�_employees(full and/ 5. ❑Retail
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity. '
(No workers' comp.insurance required] 8• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment ;
their right of exemption per c. 152, §1(4),and we have 10.Q Manufacturing
no employees. [No workers' comp. insurance required)* '
4.❑ We are a non-profit organization,staffed by volunteers, 11.0 Health Caze
with no employees. o workers' com .insurance re . 12.� Other
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*Any applicant that checks box#1 must also fill out the section below showing their workers'compensadon policy information.
**If the cotporate officers have exempted themgelves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should chedc box#1.
I am an employer that is provid' g workers'c ensali n insur^ance for my emp oyees. Below is the policy information.
Insurance Compar►y Name: � i�/ �(„n '
Insurer's Address: �J� (,� ^ il
City/State/Zip: �I
Policy#or Self-ins.Lic.# V � � Expiration Date: �7 '
Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). .
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.Oi?a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of
Investigations of the DIA for insurance coverage verificarion. i
I do hereby certify,under the pains af nalties of perjury that the information provided above is true and correct. ;
v'� ;
Si ature: Date: � E
Phon #: � J ' �
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Official use only. Do not write in this area,to be completed by c' or town o iaL
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City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office �
6.Other
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Contact Person• Phone#: i
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www.mass.gov/dia i
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