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, �, °'� � TOWN�O�'YARM'OUTA BOARD O�-I�ALTH I i � - .,�� �I
APPLICATION FOR LICENSE/PE Y,T- `�� � �
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Please complete form and attach all necessary documents by Dec ber :�„s
Failure to do so wiTl result in the return of your application ackp�qLTH DEpT. i
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ESTABLISHMENTNAME: Ls- R�0' NJ�.,/ .
LOCATIONADDRESS: f9/���v .0 � TEL.#: t""D—�"-�y.�'�3� ',
MAILING ADDRESS: w�✓T � rt UL{ t"�_� � .� ----�--�' i
OWNER NAME: fA.M P I
CORPORATION NAME (IF APPLICABLE): S/f.y �
MANAGEI2'S NAME: ��'ri.�9/1,��.ue.� TEL#• �1J� 7S D.� ..�
MATLING ADDRESS: 1",4 .y�O
PO4L CERTI�`ICATIdNS:
The poal supervisor mast be certified as a Paol Operator,as reguiretl by State law. Please list the designated '
Pool Operator(s) and attach a copy of the certification to this form.
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Pool operators must list a minimum of twa employees currently certified in basic water safety, standard First Aid C
and Community Cardiopnlmonary ResuscitaEion {CPR}. Please list these employees belaw at�d attach copies of
employee certifications to this form. The Health Department will not use p�st years' records. You must
provide new copies and maintain a file at yaar ptace of business. ;
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3. 4 �
FOOD PROTECTION MANAGERS -CERTiFICATION3:
All food service establishments are required to have at least one full-time emplayee who is certified as a Food '
Protection Manager, as defuied in the State Sanitary Code for Food Service Establishments, IOi CMR 590.Od0,
Please attach copies of certification to this applicatian. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
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PERSQN IN CHARGE: '
Each food establishrnent must have at least one Person In Charge (PIC) on site during hours of operation.
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HESMLICH CERTIFICATIflNS:
All food service establishments with 25 seats or more musk have at least one employee trained in the Heirnlich
Maneuuer on the premises at ail tirnes. Please list your employees trained in anti-choking procedures belaw and
attach capies of employee certifications to this form. The Health Depar#ment will nat use past years' reeords.
You must provide new copies and maintain a gle at your p(ace of businass. ,
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RESfiAt.JRAiv"I'SEATING: TdTAL# �a�
OFFICE USE ONLY
LODGING:
L[CENSE FtEQUIRED FEG Pl'sRM]T# LICENSB REQUIRELT f8E PERMfT# LICENSE REQUIRED EEE PERMIT#
,__BBcB $55 _ _CABIN $55 _,MOTEL $SS
_INN $55 _CAMP $55 _,SWIMMING POOL $&Oea .
_LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $$Oea. �
--.._.__.Cnt)I)�T'+,I�VIt7F.:_� � - -----....—. ._. ....__ i
LICENSE RHQUIREG FE� PERMI't tt LICBN3E REQUIRED FEE PERMiT# LSCBMSE REQltIR�D YEE PERMIT#
_0-t00 SEATS $SS _CON7'CNENTAL $35 �NON-PROFIT $30
�>I00 SEATS $160 ��� r COMMON VIC. $60 �(','����0 _WEIOLESALE $$0 „^.__
RETAIL SERVJCE: —RESID.KITCHEN $$0
� GICENSE REQUIREU FE[; Pk?RMIT# LICBNSE REQUIRED FEB PERMIT# LICENS�G+REQUIRT3D FEE PEREviiT#
_<SOsq.ft. $50 >25>OQOsg.ft. $225 _, VEND[NG-FOOB $25 ��,
_<25,000 sq.ft. $8Q � _.PROZEN DESSERT $40 �TOBACCO $95 ��
Nn�r�c�xcE: �ts AMOUNT DUE _ $ '2"ZQ • 00
*****PT.EASE TURN OVER AND COMPLETE pTHER SIDE OF FORM*****
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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 V
OR
WOI2KER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes 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 OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinazily and customazily associated with 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 �I
an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence ar
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 'I
POOL OPErTING:All swimming,wading and whirlpools which have been closed for the season must be inspected I
by the Health Depar[ment prior to opening. Contact the Health Department to schedule the inspection three(3)days
prior 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 standazd 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(7)days of '
closing. ',
FOOD SERVICE
SEASONAL FOOD SERVICE OPEIVING:
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. �
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CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the i
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be I
obtained at the Health Department,or from the Town's website at www.vannouth.ma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab priar 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 terms 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.
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 15, 2012.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF H LTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY UIRE A SIT�AN.
DATE:��/ot��vL SIGNATURE:
PR1NT NAME & TITLE: �'QGf//�j2p �, C3�,p,4d!/n.p �/t
Rev. 10/09/12 P2 p�,��Nr
Workers Cam ' ��
pensation and �mgiayers Liability ZU���H
Ins�rsaee Poliey
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