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APPLICATTON FOR T..ICENSElPERMC[at���'3'� b
* Please cornplete form and atYach all necessary docu nents by Decem er 1�D�OYaF3 2�J 14
Failure to do so will resuIt an the ret�un of your application pac etH LTH DEPT,
ESTABLISHMENT NAME: v0 ID•
LOCATION ADDRESS: p C)Cl '� TEL.#: r0 - � �'
MAILING ADDRESS:
E-MAILAL)DRES : ' OS - , t�
OWNER NAME:
CORPORATIQN NAMB F APPLICABL }: ��
MANAGER'S NAME: � � TE .#: -�
Nf�ILING ADDRESS: � c„1t}(� �y
POQL CERTIFICATIONS:
T6e pool supervisor must be certe�ed as a Paol Operator,as required by State law. Please list the designated
Pool Operator s) and attach a copy of the certification to this form.
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Paol aperators must list a miriimum af twa emplayees currently eertified in basic water sataty, standard First Aid
and Community Cardiopulmonary Resuscitation (CPR}, haVing one certified employee on premises at all times.
Piease list the amployees below and attach copies of their certifications ta this form.The Health Department wilI
not use past years' records. Yon must provide new copies and maintain a file at your place of business.
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FOOD PRdTECTION MAN�3.GERS - CERTTFICATIONS:
All food service establishxnents are required to have at least one full-tirne ernplayee who is certified as a Food
Protection Manager, as ciefined in the State Sanitary Code for Food Service Pstablishments, 105 CMR 590.000.
Piease attach copies of certifioation to this application. The IIealth Department wil(not use past years'records.
You must provide new copies and maintain a file at your establishment.
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PERS4N IN CHf1RGE:
Each foad establishment rnust have at least one Person In Char�e (PTC) an site during hours of opera6an.
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ALLERGEN CEI2TIFICATI{}NS:
All food service establishments are required to have at least one full-tirne ennployee who has Allergen certification,
as defined in the State Sazaitary Code far Food Service Establishments, 105 CMR 590.009(G}(3}(a). Please attach
copies af cartificatian to this applicatian. The Heaith Department wiil not use past years' records. Yau must
provide new copies and maintaip a�le at your establishment.
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HEIMLICH CERTIPICATIONS:
All food service establishrnents with 25 seats or more must have at least one employee trained in the Heimlich
Manenver on the prernises at all tirnes. Flease list your employees trained in anti-choking procedures below an@
attach copies of ernployee certifications to this form. The Health Deparkment will nut use past years' records.
You must provide new copies and maintain a file at your place of business.
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RESTAURANT SEATiNG: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEF. PGRMIT# LICF'NSE REQUIRED FFE PERMIT# LICENSE REQUfRF,D FGE PERMIT#
_B&B $55 CABIN $SS MOTEL $I10
_INN S55 CAMP $55 L SWIMMING PQOL S]IOea�[-[��
_LODGF, $55 �_ ='TRAILBRVARK $lOS WHIftLP00L $IlOea.
FOOD SERVICE:
[,ICENSE REQUIREll FEE PERMIT# LiCBNSE REQUTAED FEE PERMIT# LICENSF,REQ UIRGD F'EE PERMIT#
0-100 SEATS $12S C6NTINENTAI. $35 � N6N-PROPIT $30
=>I00 SEATS $200 �c�- � � �COMMON VIC. $60 �F,j —WHpLESALE $80
—RESID.K[TCHEN $8Q
RETAIL SERVICE:
LICENSE EtEQUIREI7 FEE PF.RMIT tl �LICENSP REQU[RED FPE PERMIT Jt LI(.",ENSE REQUIRF.D FEE PERMIT#
<$Osq.ft. $50 �25,OOOsq.ft. $285 VENDINCi-F60D $25
"<25,000 sq.ft. $150 _FROZ,F,N DESSERT $40 v —TOBACCq $1IO
NAMECHANGE: $15 � AMOUNT AUE _ $ ,.��jO.Q(')
*****PI.EASF.TURN OVEI2 AND COMPLF.TE pTHER SIDE OF FO •**** ��(� 't' ���•�
1 V'Q'�t� �3$3'-��
ADNIINISTRATION •
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 persan or company daes not have a Certificate of Worker's
Compensation itzsuranee. THE ATTACHED STATE WO:I2KER'S COMPENSATION IP3SURANCE
AFFIDAVIT MLTST BE COMPLETED AND SIGNED, OR
GERT. QP INSURANCE ATTACHED`^'
OR
WOP.KER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth ta�ces and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECR
APPROPRIATELY IP PAID: /
I'ES ✓ NO
MOTELS ANA CITHER LODGING ESTABLISHMENTS
TItANSIENT OCCUPANCY: For purposes of the lamitations of Motel or Hotel use,Transient occupancy shall be
limited ta the temporary and short terxn occupancy,ordinarily and custamarily assooiated 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 sha11 generally refer to continuous occupaz�cy of not more than thirty(30)days,and
an aggre�ate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or
dweliing unit shall not be considared transient. 4ecupancy that is subject to the collecrion af Room Occupaney
Excise,as defined in M.G.L. c. 64G or$30 CMR 64G, as anaended, shall generally be considered Transient.
POOLS
P40L OPEt+IING:All swimming,wading and whirlpools which have been closed for the season must be insgected
by the Health Departrnent prior to opening. Contact the Health Department to schedule the inspection three (3)
days prior to ogening. PLEASE NdTE: Feople are NdT allowed to siT in the pool area nntil the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested far pseudomanas,total colifonn and standard plate count
by a State certified lab, and submitted to the Health Department three (3} days prior to apening, and quarterly
thereafter.
POOL CLOSiNG: Every outdoor in ground swimming paol must be drained or covered within seven{7}days of
olosing.
FOOD SERVICI;
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the I�ealth Department prior to opening. Please contaet the
Health Depaztment to schedule the inspaction three (3)days prior to opening.
CATERIIVG POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temparary Food Service Appiication form 72 hours priar to the catered event. These forms can be
obtained at the Health Deparhnent,or from the Town's website at www.varmouth.ma.us under Health Deparhnent,
Downlaadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State cert3fied 1ab priar to apening and monthly thereafter,with sample results
submitted to the Heatth Department. Failure to do so wilI result in the suspension or revocatian of your Frozen
Dessert Permit until the abave terms have been rnet.
OUTSIDE CAFL+SS:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTAOOR COOKIIVG:
tJu#dcao��nnkan2,prepazaficrn,o�di�play of any food product by a retail or food service establishmcnt is prohibited.
1VOTICE: Permits run annually from January I to Dacember 3 I. IT IS YOLTR RESPONSIBILI'I'I'TO RETURN
THE COMPLETED RENEWt1L APPLICATION{S}AND REQUIRED FEE{S}BY DECEMBER I5,2014.
t1Ll RENOVATIdNS TO ANY FOOD ESTABLISHMENT, MO'PEL OR PQOL (i.e., PAINTING, NEW
EQUIFMENT,ETC.},MUST J3E REPQRTED TQ ANI?APPRdVED BY THE Bt}ARD C}F HEALTH PRIOR
TO COMMENCEM T. RENOVATIONS MA QUIRE A SITE PL
DATE: I�I STGIVATURE: 0 �
PRINT 1VAME& TI1'LE: � �i d (��(f�
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CERilFicaTE HOLDER � CANCELLATION
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THE EXW�'� DATE TXEREOF� ND110E WILL BE DELNERED IN
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