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• � TOWN OF YARMOUTH BOARD OF HEALTH -Y��,,
� � � APPLICATION FOR LICENSE/PERMIT--2013 -� �IJV O 5 2012
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* Please complete form and attach all necessary docutneIIts by Decem pr pEPT.
Failure to do so will result in the return of youi�.eC�plication pac e .
ESTABLISHMENT NAME: ��/'�6 EL0 (�/1/L�,E/J �'/�N4i,vitlJ�J TAX ID•
LOCATION ADDRESS: /2 9 7 /n.4jN STt �r�/v U,sx/r/o� TEL#•SDA-34 y2227
MAILINGADDRESS: 34! ��/tE CHD2� D.e n�/�TR�ToI�t /!!�//t�. //�A b26i��
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OWNERNAME: t�/1-ui Y ,���rv,c.
CORPORATION NAME (IF APPLIC�JABLE): L. ID J '-Sc �ua �f.Pyrc.� � �
MANAGER'S NAME: s TEL.#: - -USi
MAILING ADDRESS: o x (,:��i � �o .m /12i4 a Z6Yy
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Paot O�eratrr:�sj an�attach a eopy of the ce:-tificati�n to this form. - -
1. 2•
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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 are 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'rewrds.
You must provide new copies and maintain a tile at your establishment.
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_ PEIZSOiv� Pv' C�IAItGE: _ _ -
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
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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 a11 times. Please list your employees trained in anti-chokmg 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.
l. 2•
3. 4.
RESTAURANT SEATING: TOTAL# ��
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 _CABIN $55 _MOTEL $55
INN $55 _CAMP $55 _SWIMMING PGOL $80ea.
LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
I 0-100 SEATS $85 �/3-006 —CONTINENTAL $35 _NON-PROFIT $30
>100 SEATS $160 LCOMMON 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. $225 _VENDING-FOOD $25
<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
� NAME CHANGE: $15 AMOUNT DUE _ $ I�S.O�
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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
OR
WORKER'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,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 six(6)month period. Use of a guest unit as a residence or
dwelling unit sha11 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 inspected
by the Health Department prior to opening. Contact the Health Depar[ment to schedule the inspection three(3)days
prior to opening.PLEASE NOTE: People are NOT allowed to sit m the pool azea 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 OPENING:
All food service establishments must be inspected by the Health Departrnent prior to opeoing. Please contact the
Health Departrnent to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtained at the Health Department,or from the Town's website at www.yarmouthma.us under Health Department,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior 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 caf_e_s(i,e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd 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 3 L 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 HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY�UIRE A SI/�L�
DATE: /� 2G Z SIGNATURE: �,�,L �/ ,, `
PRINT NAME & TITLE: �j� f j��,,,!
Rev. lO/09/12
`'��� CERTIFiCATE OF �IABILlTY lNSURANGE g/30/2612'
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7HI5 CERTIFICATE IS ISSIfED AS A iNATTER OF INFORMATION ONLY AND CONFER$ NO ftIGHTS UAON THE CERTIFICATE HOLDER. THIS
CERTIPICATE WES HOT AFFIRMASIYELY OR NEGATEVELY AMEN6, EJ(TEND OR AITER THE Q(3YERpQE AFFOROED BY THE POLI�IES
BELOW. THIS CERTiFICATE OF 4NSURANGE DOES NOT CON5TIME A GONTRAGT BE7VYEEN 7HE ISSUING INSl1RER{5), AU7HORIZEO
ftEPRE3ENTA7IVE OR PRODUC£R,ANO FHE CERTIFICATE MOLDER.
iR8'ORTANT: Lf the terUleate holder is an ADORiONA�INSUNED,the poiiey{ics)must 6¢andorse�l. 1!SUBROGA71pN IS WA15�0, subject to
tha terms and wn6lions of the polky,certain poftcias may�equire an¢ndarsemeM. A statert+ent on this certificate does not confer rigMs to thc I
cenifica[e holder in lieu o/such endoreomon s. � '
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