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�, � � TOWN OF YARMOUTH BOARD OF HEALTH .
, APPLICATION FOR LICENSE/PERMIT -2013 N�V I � ��I1� �
�� * Please complete form and attach all necessary documents by De m PT.
Failure to do so will result in the return of your application p .
ESTABLISHMENT NAMEZCIom � TA I •
LOCATION ADDRESS: a S. R TEL.#: – O - 6 C)
MAILING ADDRESS: !a
OWNERNAME: � �
CORPORATION NAME (IF APPLICABLE): Z K .r c •
MANAGER'SNAME: �LFF' TEL.#: yI�l�
MAILINGADDRESS: q ute a8 S•��u� t,r- Dalolo�
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by 5tate laev. Please list the designated
Poo3 f3prratci�(sj ar,d-attack���pyaf tYhe cei�ificatioi�ie this sonn. --- ---- — - —
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary 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.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze required to have at least one 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 Deparhnent will not use past years'records.
You must provide new copies and maintain a C►le at your establishment.
t. l,U� I��c�-�v�, � Su.� n���Rs� 2.
�ERSON f:�I eHAREEr _ __ __ _ _ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�.u>,(j;�t,M �S S�X ��-�a,�, z. ,.��cQz.� I�A�v�L�-
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures 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.
1.�-e��-� �U �-vri 2. L�e
3. ;�c� (d� � 1�,� 4. nn e �
RESTAiJRANT SEATING: TOTAL# _/�¢D
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CriBIN $55 _MOTEL $55
_INN $55 _CAMP $55 _S WL'v[MING POUL y80ea.
_LODGE $55 TRAILERPARK $]OS WHIRLPOOL $80ea.
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-IOOSEATS $85 _CONTINENTAL $35 NON-PROFIT $30
�>100 SEATS $160 �3'Q�3 �COMMON VIC. $60 3—CIOg _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
[,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<SOsq.ft. $50 _>25,OOOsq.ft. $225 VENDING-FOOD $25
Q5,000 sq.R. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 � AMOUNT DUE _ $ 2Z0 .Q p
****"PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM***"*
ADMINIS'1"RATION ,
IJnder Chapter 152,Section 25C,Subsecrion 6,tlle Town of Xarmouth is now required ta hold issuaace or renewal
of any license or permit t4a operata a business ii'a person or company daes nat have a Certificate of Worker's
Compensation Insuranee. THE ATTACHED STATE WORKER'S COMPENSATTON IPISUTZANCE
AFFIDAVIT MUST BE COMPLET�D AND SIGNEll, OR
CERT. OF INSf3RANCE ATTACHPD
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND A'1'TACHED
"I'own of Yarmouth tazces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES�_ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCU PANCY: Far purpases af the limiiations af Motei or Hate2 nse,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrata that they maintain a prittcipal ptace of residence
elsewhere.Transient occupancy sha11 generally refer to continuous accupancy 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 ca(lection of Room Occupancy
Excise, as defined in M.G.I.. c. 64G or 834 CMR 64G,as amended, shalt generally be considered Transient.
POOLS
POOL OPENING;All swimming,wading and whirlpools which have been closed far the season must be inspected
by the Health Deparkment priar to opening. Contact the Health Department to schedule the inspection three(3)days
prior to opening. PLEASE NOTE: People aze NOT allowed to sit m the poal azea until the pool has been inspected
and opened.
Pt}4L WATER TESTIIYG: The water musE be tested far pseudamonas, total eo2ifarm and standard plate count
by a State certified lab, and submitted tp the Hcalth Department three (3) days prior to opening, and quarterly
thereafter,
POOL CLOSING: Every outdoor in ground swimming poof rnust be drained or covered within seven(7}days of
olosing.
Ft70D SERVICE
SEAS4NAL F40D SERVICE C}PENING:
All food service eskablishments anust be inspected by the Heaith Departrnent prior to opening. Please contact the
Health I?epartment ta schedule the inspection three (3}days prior to opening.
CATFRING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health I7epartment by filing the
required Temporary Food Service Applicatr`on farm 72 houts prior to the catered event. These fatms can be
obtained at the f�ealttt Deparnnent,or from the Town's website at wu�v.vannauthma.us under Heaith Department,
Downloadable Forms.
F120�EN DESSERTS:
Frozen desserts must be tested by a State certified]ab prior to opening and monthly thereafter,with sarnple results
submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Prozen
Dessert Permit until the above terms have been mef.
OUTSIDE CAFES:
Outside cafes{i.e.,autdoor seating with waiterlwaitress service),must have priQr approval from the Board of Health,
- ------ -- - -- _ ___ __ _
OUTDOOR C40KING:
Outdoor cooking,prepazation,or display of any foad pxoduct by a retail or food secvice establishment is prohibiYed.
NQTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWA.L.APPLICATION(S) AND RE;QUIRED FEE(S) BY DECEMBER 1S, 2012.
ALL RENOVAT10N5 TO ANY FOOD �STABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NBW
EQUIPMENT, ETC.),MUST BE REP012TED TO AND APPROVED BY THB BOAR17 OF HEALTH PRIOR
TO CONiMENCEMENT. RENOVATIONS MAY REQLTIRE A STTE PLAN.
DfiTE;�f Jd.- SICTNATURB:��� 1��� _JVIL/I�/�� .
PRINT NAMB& TITLE: (,f��I It.,t na � �`7_���f����+'�% ,,�Y��;�,.Q�,7'
Rev. 10/p9/l2
• � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office oflnvestigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le¢iblv
Business/Organization Name: Z{�cvV� y/K. d brs- j o U Les s rRn I
Address: �,���(.2 ,� �
City/State/Zip: � �ytou � l�'LdG(P Phone#: �(}��7�p -/OD �
Are ypu an emptoyer?C�iecTt tlie appropriate box: Business Type(required):
__ _ _ ----
1.0 I am a employer with�_`�employees(full and/ 5. ❑ etail
or part-time).'" 6. [�RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, � 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.❑Manufacturing
no employees. [No workers' comp. insurance required]* I 1.❑ Health Caze
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑ Other
`My applicant tha[checks box#1 mus[also fill out the section below showing[heir workers'compensa[ion poliry infomtation.
"If the corporate officers have exemp[ed Shemselves,bu[[he corpara[ion has other employees,a workers'compensation policy is required and such an
organiza[ion should check box#I.
I am an emp[oyer that is providing wo,rk/ers'compennsation insurance jor my employees. Below is the policy informa8on.
Insurance Company Name: �-e- �/p-rt�yj('pL
Insurer's Address: �j�0'�'�6� J�LJ} Z/�}
c�cyisr�t�z�p: f�1y-Fk�v r� L'7 D�lI�
-Poticy#-or�ztf-ins.i,ic.�A`---�'$�c3�F.G ���'{c�-- .�- ._..----- � LxpirationDst�:-�/�l� _
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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 verificalion.
I do hereby cer[ify,under the pains and penalties ofperjury that t6e information provided above is bue and correct.
xSipnature: Date• ��/���'
Phone#• J'Td� 7�6� ��57�
Official use only. Do not write in this area,to be completed by city or town ojficial
City or Town: Y�}Q�1'�D� Permit/License#
uing Authority 'rcle one):
1.Board of Heal .Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.
Contact Person: Phone#: �8—c3�8��- j X �Z�( �
www.mass.gov/dia
CIfo�Mlk 1&1&T 2DDYLESREt �
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� ��� ,: �'�a TOWN OF YARMOUTH
� � "3 11�G ROI;TE 28 SOL'TH I�1R�IOUTH \I�ASSACHi;SETTS 02669-4451
� MATTACIIfES �
�w,��w��,,.o� ia' Telephonc �508` 398 2231. Ezt. ]241 — F2� ;�08i 760-3472
6�'
B O A R D O F H E A L T H
November 14, 2012
William J. SurprenanUZDom Ina
d/b/a Doyle's Restaurant ���
1329 Route 28 �'`�'��bs�oD
South Yarmouth, MA 02664 h�nv „ � n
' 1 ,: ;1:
,�
Re: 2013 Application for Licensing H�LTi�8�p�
� �� � .m..,,,.
k _
Deaz Mr. Surprenant, 3" °C��-�^�j�' �3
.
Thank you for submitting the year 2013 renewal application for your establishmenYs food service
and common victualler permits issued through the Health Department. However, we aze unable to
process the application at this time because there was no payment enclosed. The total amount due
for your license renewal is $220.00 .
Please remit your check,payable to the Town of Yannouth,to the Health Department. As soon as
our office receives your payment, we will be able to process the application.
If you have any questions on the above, please feel free to contact the Health Department at
(508)398-2231, ext. 1241. Thank you for your anticipated cooperation.
Sincerely,
��/����
Mary Alice Florio -
Principal Office Assistant
cc: file