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� � � TOWN OF YARMOUTH BOARD OF HEALTH � :
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�� APPLICATION FOR LICENSE/PEI�VIIT-2009 ' \�,�� J ;
�� * Please complete form and attach all necessary document`s_by'-�ecem��2BB8: �
Failure to do so will result in the return of ycsttt apphcahon packet.
NAME OF ESTABLISHMENT: dS ��'vt�t- � I � TEL. # S�d'' ��`! �`��
LOCATION ADDRESS: 6 2_ � � /c S y,4'/�/!rc �+-�/i G[�6 �
MAILING ADDRESS:
OWNER NAME: �9.J�l�i A>"� ✓�� /I.a1�-� TAX ID (FEIN or SSNI: 6(S`SLD 3 7J
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: / , ..o ,.c,/�-� TEL. # �d'' 6 - �-S J
MAILING ADDRESS: G 'L ��.S.d� �4/�Mu , ✓'�l f�. � �� �
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Poo(Operator, as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees cwrently certified in basic water safety, standard First Aid and
Community Cardiopulmonazy Resuscitation(CPR). Please list these employees below and attach copies ofemployee
cei7ifications 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 are requn•ed 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.
1. /�l/j ��i �°i!.-t ��nA )✓ 2.
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PERSON IN CHARGE:
Each f'ood establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. �,1 ��iA•`1 /i'!J/��J 2.�i✓iC�QiCel? �:./t��*'/`�
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Hennlich
Maneuver on the premises at all tnnes. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to tlris foi�n. The Heaith Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
I. � � l/,a-y ,/�,�r�rv,�-� a. �- �.ti. ✓�Corto+�/
3. S„ � ,�r �2�.�✓ 4. ��., n �;z.�✓
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGIVG:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItbD FEE PERMIT# LICENSE REQU[RED FEE PERMIT k
B&B S55 CABIN S55 _MOTEL S55
IIviv S55 CAMF S» _SA�IMNIINGYOOL 580ea.
LODGE S55 IRAILERPARK SI05 _WHIRLPOOL S80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT t? LIGENSE REQUIRED FEE PERMIT H
�0-100 SEATS S85 �O�j^l�J _CON7INEN-IAL S35 NON-PROFII S30
>100 SEATS 5160 1 COMMON VIC. S60 '� �bS�I _WHOLESALE S80
RET91L SER�7CE: —RESID.KITCHEN SRO
LICENSE REQUIRED FEE PERMIr# LICENSE REQUIKED FEE PERMIT# LICENSE REQUIRED FEE PERMII'#
vOsq.ft. S50 _>25,OOOsq.ft. 5225 VENDING-FOOD S25
<25,OOOsq.ft. S80 _FROZENDESSERT 540 �ACCO SSi
v.a�7E cx,��cE: sio AMOLTNT DUE _ $ � � � �
FFtt*•pLEASE TL'R\OVERA\'D CO.�IPLEIE OTHER SIDE OF FORVI**`"*
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town ofYarmouth is now required to hold issuance or renewal
of any license or pemut 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
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth ta�ces and liens must be paid prior to renewal or issuance of your pernvts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES ier NO
MOTELS APiD OT`HER LODGING ESTABLISIiMENTS
TRr1NSIENT OCCUPANCI': For purposes ofthe limitarions ofMotel or Hotel use, 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 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 an
aggregate of not more than ninety(90) days within any s'vc(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 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
POOL OPENING: All swimming,wading and whirlpools which have been closed for the season must be ins ected
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection five(5�days
pnor to opening. PLEASE NOTE: People are NOT allowed to srt m the pool area until the pool has been inspected
and opened.
POOL WATER TEST'ING: The water must be tested for pseudomonas,total coliform and standazd plate count
by a State certified lab, 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
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the requued
Temporary Food Service Application form 72 hours prior to the catered event. These forrns can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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 ofHealth.
OUTDOOR COOHING:
Outdoor cooking, prepazatioq 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. TT IS YOUR RESPONSIBILTI'Y TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRI:D FEE(S)BY DECEMBER 15, 2008.
ALL RENOVATIONS TO ANY FOOD ESTABLISHNIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COIvIMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: Z �j �' SIGNATURE: � � l��
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