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� TOWN OF YARMOUTH BOARD OF HEALTH ° [�C�C�O D
e � � APPLICATION FOR LICENSE/PERMI�'=�D15 ' ` �
� .�o3�s� NI�V 2 5 `l�t�
* Please complete form and attach a11 necessary docum�ts by Dece ber 1 S 2014.
Failure to do so will result in the return of your application pa et}{Eq�TH DEPT.
ESTABLISHMENT NAME: �+- TAX ID: �
LOCATION ADDRESS: ��I'1 �l.�u�M Sl1n rP_ fhn�,-e TEL.#: 50 " �� �`�O
MAILINGADDRESS: ��� 3'1U �l��rr.-�a� {�-2-�1— G�,.FrY
E-MAILADDRESS: 1-C� (1� (f�I . C0i"�
OWNERNAME: .�'�'1 ,Sautn Shart h,-wc. LL
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: ��'(G D1 �ioUunn� TEL.#:� 3Q ' �I
MAILINGADDRESS:��c:��'�(L. .��vv�,n�'1 �t-�.4 /5�-�oCo ;J
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
l. J IIV11tM�nG phGl ��7G1 �Si�✓� � J�C V � 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at all times.
Please list the employees below and attach copies of their certifications to trus form.The Health Department will
not use past years' records. You must provide new copies and maintain a Sle at your place of business.
1. P(a�'�Cla 11'1Gt�Dn`� 2.�r;irY;lfu �76 �a�� nri
3. �gM��tt �� 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 Department will not use past years'records.
You must provide new copies and maintain a file at your establishment.
L 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
L 2.
ALLERGEN CERTIFICATIONS:
All food service establishxnents are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
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 Sle at your place of business.
1. 2,
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
_B�B $55 CABIN $55 I MOTEL $110 � -0{�}
INN $55 —CAMP $55 i SWIMMINGPOOL$110ea.
_LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $il0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100SEATS $]25 _CONTINENTAL $35 NON-PROFIT $30
_>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
_Q5,000 sq.ft. $150 _FROZEN DESSERT $40 =TOBACCO $t 10
NAMECHANGE: $IS AMOUNTDUE _ $ 2Zo.00
****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•*** F�'`�� ��3��U
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ADMINISTRATIOiV
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Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any.Iicense or permit to operate a business if a pezson or company does not have a Certificate of Worker's
Compensarion Insuranee. TFIE ATTAGIiED STAT'E WQRKER'S CQMPENSATIQN Il\'SURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF 1NSLTRANCE ATTACHED �
G1R
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHF.D
Town of Yarnyouth taatcs and liens must be paid p 'or to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATBLY IF PAID:
1`ES NO
MOTFLS ANll OTHER L4DGING ESTABLISHMENTS
T[2ANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
lirnited to the temporary and short term occupancy,ordinarily and eixstomarily associated with motel and hotel use.
Transient accupants must have and be able ta demonstrate that they maintain a principal ptace af residence
elsewhere.Transiettt occupancy shall generally refer to continuous nccupancy of not rnore 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
dcvelling unit shall not ba considered transient. Oecupancy that is subjeet to Ehe eollection of Raam dccupancy
Excise, as defined in M.G.L. c. 64G or 830 CMR 64Ci,as amended, shall generally be considered Transient.
POOLS
PQQL OPE11tING;A11 swimming,wading and whirf�ools which have l�een ciosed fos the season rnust be inspected
by the Health Uepartment prior to opening. Contact the Health Department to schedule the inspection three(3)
days prior to apeoing. PI.�ASE NOTE: Peaple are I�O`T allowed to sit in the pool area until the paal has been
inspected and apened.
POOL WATER TESTING: The watex must be tested for pseudomonas,tatal coliform and standard plate caunt
by a 3tate certified lab, and submitted to the Health Department three (3} days prior ta o�ening, and quarteriy
thereafter.
P(}OL CLOSING:Every outdoar in ground swimming paol must be drained or covered within seven{7)days of
closi�g.
FCMOD SGI2VICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Departmant prior to opening. Please cantacY the
Health Department to sehedule the znspectian three {3)days prior ta opening.
CATERING P4LICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 'hQurs priar Co the catered event. These forms can be
obtazned at the Health Department,or frorn the Town's website at www.�umoukhma.us under Health Department,
Downloadable Farms.
FROZEN DESSERTS:
Frozen desserts must be tested by a 8tate cerfified lab prior to apening and monthly thereafter,with sample results
submitted to the Heatth Department. Failure to do so will result in ttze suspension or revocation of your Frozen
Dessert Permit until the above terms have been n1et.
OUTSIDE CAF'ES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval frorn the Board of Health.
OUTDOOR COOKING:
Gut-t�or coakiag;pfeparetien,pr dispIayvf any f�nd praduct by a retail.or faod service establishmenT is gro6ibited.
NOTICE:Pernuts run annually from January 1 to December 3 I. IT IS YOL1R RE3PONSIBILITY TO RETUIZN
7'HE COMPLETF,D RENEWAL APPLICATION{S}AND REQUIRED FEE(S}BY DECEMBER 15,2014.
ALL RENOVATIONS TO ANY FO(3D ESTABL.ISHMENT, MOTEL OR POOL (i.e., P.�IN`T`ING, NEW
EQUIPMENT, ETC.},MLIST�E REPORTEZ}TC}AND APPRQVED BY THE B(�ARD OF HEALTH PRIOR
'CO CQMMENC�MENT. RENOVATIONS MAY REQUII2E A SITE PLAN.
DATE: l�� / ��f SIGNATURE�(1 �' � �
PRTNT NAME&c TITLE:�/f'/G�/"G ,Ol�iaiG�`�r%, /`j�/��G t"!�
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THIS CERTIFICATE 1S ISSUED AS A MAT7ER aF qlft)RMAtIOk ONLY ANO Ci�IFER3 NO RICaHT3 UPON THE OER'i7FlCATE HQtDER.THIS
CER'11flCATE DOES NOT AFflF2MATIYELV OR NBGATIYE4Y AMEND, EXTEND QF2 ALTER THE COYERAOE AfFARDEtI BY 7FIE PdUqES
BELOW. THIS C8R71FlCATE pF INSURANCE DOES NQT CQN$TITtlTE A CONFRACT BE7WEEN TH� IS8ilING INSIIRER(S},AUT}iORSZEA
REPt'�SENTATIVE OR PRQDUCER,AND THE CERTIFlCATE HOLDER.
iMPpRTANT: tF the tertiflcete halder is en ApDtT16NAL MISURED,ti�e poliay(i�)must be�redo�sa0. If SUBttOGAT{Oh IS WAIYE6,aut�ject to
dus tem�s a`d candit7ons M the pd(cy.certain�Ileies may mqWre an e�nrsenfent A stabament at ttds caeHflcide�rmt coMar righfs ta tfk
eertifrcate hdder in�ie�u of such 8.
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INDICATED. NOTWRHSTA.NDING ANY RElN11REMENT.TERM OR CONGfTlf.lN OF ANY CONTW0.CS OR OTHfR�UMENT WlTft RE'SPECT T6 WHICt1 THIS
CERTIFiCA'fE MAY BE GSSUED OR b1AY i�RTA1N, THE INSURANCE AFFORDED 6Y THE PdIJC1E$ DESCRIBEO MEREIN !.4 Si19JECT TO ALt 3'HE TERMS,
EXCLUSIONS APPXt t'.QNDlT10NS�SUGH FOltCIES.11MARS SFiOWN MAY HAVE BEEN REIXICED BY PAIG CWMS.
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