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� TOWN OF YARMOI7TH BUARD OF HEALTH
APPLICATIOl�t FQR LICENSEtPERhIIT-2Q1Z
*Please complete form and attach all necessary documents by December I 201b.
Faihme to do so wit�result in the retxttn of yow appticahon pac et.
ES�'AB�SF�MENF NAME: r�` • o - Sb y�n
LQCATTON ADDRESS: c� � TEL.�: f> � O
MAILING ADI?RESS:
E-MAIL ADDRESS: [c� t!
OWNER NAA�: •
_ ____
CORPORA'L'�aN N.AME.(IF APPLICA�I.E;_
MANAGER'S NAME: �is+�i��J� ,�iG� TEL.#: �'�t�
Nr�A�.Il�iG ADDR�SS• �'�
i r. "—�'-T.—.
F�Wt,4Li'R t iP�T�[2 f TQiY.7:
The pool sapervisor muat be certified as a Pool Opemtor,as reqnired by S1�te IAw. Ptease list the design�ed
Pool Operator�s)aad attach a copy of ths c�xtific�n ta this fo�n.
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Faol operators must list a minimum of two emplayees cwrendy certified in standard First Aid and Coannunity —ri ;--=- m
� Gazdiopuimanary Resuscitation(CPR�tsaving one certified employee on at att times. Please tist the = ;��
employees below and attach copi�of tbeir cerqfications to this form.The�[a��l�Department w�not use P*at �' ,.,� �
i ye,srs'recer�da. �on a�ast previde uw c�pi�s sad sa�tain a�e a!�r gi�e of bnsme.�. � c� �
} 2.
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3. 4.
FOOD PROTECTTON MANAGERS-CERTIFICATlONS: ,
AU food service establishments are r�uired to have at least one futl-time employee who is certified as a Food "Y`';
,Prof�tion Manager,as defined in the State Sanitary Cade for Foad Service Establishments,105 CMR 590.OQQ.
Please attach copies ef certification to this apglicatioa. The H��art�ent w+7i eot ose past years'recorda, ��;
You mast provide new copies and mamtam a Sk at your eabbiishmen�. �.:=��
1. 2. . i�����
PERSON IN CHARGE: �:`
Each food establishment must have at leasE one Peison In Charge(PIC)on site during hours of operation.
��
1. 2.
ALLERGEN CERT�ICATIONS:
Ali food service e.stablishments are requirai to have at Ieast o�fuil-time employee w�has Allergen cettification,
as defined ia tl�State Sauitary Code for Food Service Esmblishments,105 CMR 540.OQ9(Gx3}(a)• Please�
copies of�erti$cation to th[s apptication '1'�e HcaltL Departme�t w�t eot�se past yeus'records. Yan sost
provide 0ew eopies xnd maiatxia a Sle at yonr establishmen�
l. 2.
HEIMLICH CERTIFICATIONS:
1�t1 food service establishments with 25 seats or more musi have at least o�e�►pioyce trained in tbe Heimtich
Maneuver on tt�e premises at alt times. Please list your emnployees t�ained im e�x1i-choking procedtues betow ffid
attach copies of emptoyee c+e�tifications to this foim. T�e Health� t w�ill aet�past yeara're�ords.
YQn iannat grn�neir cupies nsd mnintnin a fik at yanr place af u�a�us'n eess.
1. 2.
3. 4.
RESTAURANT SEATII�IG: TOTAL#
O��USE ONLY
LODGINC:
LiCENSE REQOIRED FEE PERMIT N LICENSE REQUIRED FEE PEitM1T# LICENSE REQUIRED FEE PERMIT#
B&B SSS CABIN S55 MUTEL 5110
��ADGE �5 � CAMP SSS ,_SWIMMING POOL�1 t0ea
�"�rj�i TRAILER PARK SiOS _VJfIIRI,FOQL S110ea
PQOD&ERVICE:
' LI(�NSE�(}[RRED FEE PERMIT N LICENSE REQUIRF.D F�E PERM[T# LICENS6 REQE7IRED FEE PERMIT#
0-I00 SEA'1'S S125 _CdNTII�ENTAL S35 NON-PROFII' S30
>100 SEATS SZ00 ,COMMON YIC. S60 �WHOLESALE S80
—RES�D.IEFFEHEN S84
RETAIL SERVICE:
L[CENSE REQtI[RED FEE PE:RMIT N LIGENSE REQIJtRED FEE PERMff# LICENSE REQUIRED FEE PERMiT il
<50sq�8. S50 >2i,000 ft. T285 VEND[Nd-FOOD S2i
=QS,OOO sq.R 5150 �ROZEN�SSERT S40 ='I'OBACCO 5110
r�e c�►�vice: s�s AME)U1+Ff'DUE = S 55.00
rr�:aPLLA3E T1TRN OVER AND COMPLETE 0771ER SIDB OF AORM**awr 40µ(„���–60�3'�ZJ
r
- AHMINISTRAT`tON
LTnder Ghapter 152,S�ion 2SC,Subsec6on 6,the Town of Yarmouth is now required to hotd issuance or renewal
of any ficense or permit to operate a business if a peison or compeny does not have a faertificate of Wnrker's
Campensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIUAVIT MUST BE COMPLETED AND SIGNED,QR
CERT.OF INSURANGE ATTACIiED
OR
WORKER'S Cl�MP.AFFIDAYTT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YE� NQ
MQTELS AND OTHER IADGING FSTABLISHN[E1VTS
TRANSIENT OCGUPANCY: For purposes of the Iimitations of Motet or Iiatet use,Transieat occupancy shatTbe
innited to tl�temporary and short term occupa�y,ordinarily and ceLstomaiily associated with motel snd hotel u�.
Tr�nsient occupsnts must l�ave aad be able to demonstcate that tbey maintain a prir�cipal place of residence
e}sewhere.Transient occupancy shatt generatly refer to continuous occupancy of not more thaz►thirty(3Q}�ays,aact
an aggre�ate of not more than ninety(90)days within any six(�month period. Use of a guest unit as a nesidence or
dwelling unit shal!not be considered transient Ocx:upancy that is subject w the collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 83d CNiR 64G,as amended,shs11 generatly be ccrosidered Transient.
POOLS
I'OOL OPENING:All swimming,wading and whirlpools wlvch have been closed f�the se�oai must be inspected
by the Aealth DepmrmRent o�r to o wg. Contact the Health���me�rt ta scbedak t�e ies�p�h'oa t6t�e(3)
days prior to ope�i�g.p�,$�;Peapie are NOT allo to sit in the pool area tmtil pool hes been
iauspected and opened•
POOL WATER TESTIl�iG: The water must be tested for pseudomonas,total coliform�nd standard plate count
by a State certified!ab>and submitted w the Heaith Departmern three{3)days prior to opening,and quarterly
�1CFC$�CF.
POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of
closing.
�OUD SERV[CE
SEASONAL FOOD SERVICE OPENING:
Atl food service establishments must be inspected by the Health Department prior to op�in�. Pleax c�ontact the
H�1th IZe¢�armient ta schedula the in.�pection three(3j days griar ta a�utug,
CATERING POLICY:
Anyone who caters within the Town of Yazmouth must notify the Yarmouth Health Dep�rt�nent by filing the
required Tempor�y Food Service Apptication form 72 hoitts prior to the catered eveirt. These fonns can be
obtained at the Heaith Department,or from the Town's website at www.varmiouth,.ma.us under Health Depertment,
�b�v�loadabi�Fcxms.
FROZEN DESSER'TS:
Fmzen desserts must be tsstecl by a State certified lab prior to opening and monthly ther�after,with s�tple results
submiited to the Health Department. Failure to do so will tesult in the�spension or ravocation of your Frozen
Dessert Fermit unti2 the above terms have bcen mef�
OUTSIDE CAF�S:
Outside cafes(i.e:,outd�r seatingwith waitet/waitress service),must haveptior approval frotnthe Board of�ieahh
! pi7TDOOR COOKING:
; Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohbited.
NOTICE:Permits run aanually from January 1 to December 31.IT IS YOUR RESPONSIBII.iTY TO REIURN
'F�EE COMg�.E'FEn RENEVI�AF.AP�PLICA'FIf3N(S}AND RBQUIREII REE(S}BY DECEMBER l6,�416.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.�., P.�IINTING, NEW ;
� EQU[PMENT,ETC.),MUST BE REPORTED TO OVED BY THE ARD,OF TH PRIOR !
' �ro eo�rre��. �rrv�A��oxs�� �s
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DATE: �—I��(D SIGNATURE:
PRIlVT NAME 8c TI'ff,E: y G�` _ �
t ,
,�,�,,.�awtb
� The Co»inwnwe�ltb of Massachusetts
Departmerrt of Indus�i'atAccid�nts
Q,�`'ice ef�nvestigatu►ns
1 Corigress S�ireet,Stute 104
Boston,MA OZll4-2017
www muss.gov/dia
Workers' Campens�tion Insnraace Af�idavit: Genersl Bnsinesse�
An►alicant Inf`ormatiun Ple�se Print L�ihi�,r
BusinesslOrganization Name: � �i l�Es"
Address:����,��.c�%�'l SDc�/!-����is�t��r�"�olo �,/
-.r--r--. �--�
City�Statel2ip: Phone#: S"��8���S�O
An yon an emptoyer"C�ck t�e aFPmPriate boz: B���TYPe ti''a1���1:
1.❑ i am a eanployer with emgloyees(full andl 5. ❑Retail
or part-time).* 6, []RestaurantJ'Bar/Eating Estabiishment
�Q I sm a s�t�praprietor or partnership and hav�no 7. Q O�ce antifor Sates f incl.reat estate,auto,etc.}
employees working far me in any capacity.
�o workers'comp.insurance reQuire,cl] �- ❑Non-p��it
3. �iVe are a corporation and its officers have eJcercis� 9. ❑EntertaitnFne�t
their right of eacemptian per c. 152,§I(4�,and we have 1 p_0����
no employe�s.[No worke,rs'comp.instu�ance ra}�recF}� t�.[]xealth Car�e
4.Q We are�non-profit organization,staffed by volunteers,
with no employees.[No workers'comg.insurance ra9-1 12.[�
',4ny appti�nt d�t a�Cs baoc#t�sc also fcn o�rt el�secxion bebvv�owing�eir,Mork�s'o�a polic�►�or�aa.
ss�the oo�po�ate offioers have ex�op�ed them�elves.bu�tfie c�poration hmms oti�'eaeployees,a wo�ers'o�oo P��Y��N�m�d stx�aa
otganiz�io�n should chedc box#i.
I a�e an en�ptoyu that�s prov�g workers'ca��rpensatlon�rance for my elrtp�foyets. Setow is die po�cy�iefor�tiorr.
Insurance Company Name•
Inswer's Address:
City/State/Zip:
Poticy#or Setf-ins.Lic.# �P�Qz�=
Attach A copy af the�rorkers'compeasativn poti�.y declarstion paege(showieg the policy snmber aad ezpiratio�e date�
Failure to secure covera�e as required under Sectian 25A of MGL c. 152 can lead to the impositian of criminal penalties of a
fine up to$Z,S�ff.4Q sndior ane-Ycmr"imP*isonmeM,as well as civit�in the���f a-�STt?F�ORI�L)RDE�snd�fi�e
of�to 5250.00 a day ag�ainst the vioiator. Be advised t�at a copy of this sta�nent may be fon�vaided to the Office of
Iiivesti�aRia�of the DIA farr insurance cavera�e v�ari�icatictr�.
I do hereby ' , tlte o per,jary that the tnformatfon prov�6ed abr►ve is true and aurrec�
�
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P #• � �
Q,f�9cia1�se oxly. Do�t i��ik��tta,to be cori�ted by cPty or tawr�officiat
eity or Town• Permitti.�cense#
I�aigg A�thority(carcle oae}:
1.Boa�rd of Hea[th Z,BaiWi.g D�p�rtme�t 3.G�tpfl'owa Cl�k 4.Liceasing Board S.Selectmen's Otfioe
6.Other
Coatact Ferson• P'�oae#•
www.mags.gov/dia