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. ��� TOWN OF YARMOUTH BOARD OF HEALTH ����D
APPLICATION FOR LICENSE/PERMIT- 11 ''
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* Please complete form and attach all necessary d 1� �a�� �
Failure to do so will result in the return of yoiir a ` io pa • TH DEPT.
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ESTABLISHMENT NAME: W � � - 1�- �L-L • TAX ID: - �- ( i
LOCATION ADDRESS: �31 � 'M(�;t v� S' �•�(G11'IYtO TEL #• ��S-�IG���f16a I
MAILINGADDRESS: �31�? 'rnA�✓1 g-� 8 . Yo�rmo�c�-1., �'Y�� Qa6 �F � I
OWNER NAME: Y99vlQ Lpc� - ' '
CORPORATIONNAME IF�APPLICABL ): E�-(a✓� ✓i ,�nG .
MANAGER'S NAME: (aw� �2.I P�� - TEL.#: '�'D =� o-�(,o
MAILING ADDRESS: (�I� , Y�'lcu n gfi , • `fafMo 0.16
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State la�v. Please list the desienated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a mniimum of two employees cun•ently certified in basic water safety,standard First Aid aud I�
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this foim. The HeaUh Department will not use past years' records. You must provide new
copies and maintain a 61e at your place of business.
L 2.
3. 4. i
FOOD PROTECTION MANAGERS - CERTIFICATIONS: ,
All food service establishments are required to have at least one full-time employee who is certified as a Food i
Protection Manager, as defined 'ui the State Sanitary Code for Food Seivice 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. i
1. 2. '
PERSON IN CHARGE:
_ _ _ _ _ --- -
Each food establislunent must have at least one Person In Charge (PIC) on site duiine hours of operation.
1. YOOn� 1-0k.A.:) 2. �
HEIMLICH CERTIFICATIONS:
All food service establislunents 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-chokine procedw•es below and
attach copies of employee cenifications to tlris form. The Health Department will not use past years' records.
You must provide new copies and maintain a �le at your place of business.
1. 2
3. 4.
RESTAURANT SEATING: TOTAL #
i
OFFICE USE ONLY
LODGI�G:
LICENSE REQUIRED FEE PER'vItl� LICENSE REQUIRED FEE PER��IT?� LICENSE REQUIRED FEE PERbIIT�
_B&B S55 _CABIN Sii _\40'IEL 555
_A+N SSi � � _CA;ti1? S55 _S��'L'.�4INGPOOL 580ea. ���.
_LODGE S55 _�IRAILERPARK 5105 _�4-HIRI,pOOL S80ea. !
FOOD SERV[CE: � � �
LICENSE REQUIRED FEE PERiV1IT z L[CENSE REQUIRED FEE PERbIIT r LICENSE REQUIRED FEE PERMI?_
I 0-100 SEATS S85 O _CONI'INENI'AL 535
� � _NON-PROFII' S30 �
_>100 SEATS 5160 �CO?vIIviON VIC. S60 � ��00�.3 _NHOLESALE S80 '
RE7.III.SER\7CE: —RESm.KI7CHEN S80 �I
LICENSE REQUIRED FEE PER�I[T# LICENSE REQUIRED FEE PER�III # LICENSE REQUIRED FEE PER�III ?� �I
_<SOsq.ft. S50 _>25,OOOsq.ff. 5225 VENDING-FOOD S25 �
— I
<25,000 s R. S80 �
— 9• _FROZEN DESSERI' S40 'IOBACCO S55
\A�qE CHA\GE: S15 AMOUNT DUE _ $ �4 5 .UO
•""""PLEASE'IUR�OVER A\D COviPLE?E OiHER SIDE OF FOR�1**"**
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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 INSLTRANCE ATTACHED�
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �6� ��
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
AiQT'�+L3.�.ND�TH��:LQtDG�TG ESTABLISHMENTS
TRANSIENT OCCUPANCl': For purposes ofthe 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 ofresidence elsewhere.
Transient occupancy shall generally refer to continuous occupancy of not more than ti�irty (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 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 inspected
by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days
pnor 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 wliform and standard plate count
by a State certified lab, and submitted to the Health DepartmeM three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pooi 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 Department prior to opening. Please contact the
Health Department to schedule the inspechon three(3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heaith Deparlment by fiting 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.yarmouth.ma.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 resuks
submitted to the Heakh Department. Failure to do so will result in the suspension oc revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress seryice),must have prior appr�val fromtheBoazd ofi-Iealth: --
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail or food service establishmern is prohibited.
NOTICE:Permits run annually from 7anuary 1 to December 31. TT IS YOUR RESPONS1BILiTY TO RETtJRN
TI�COMPLETED RENEWAL APPLICATION(S) AND REQUIliED FEE(S)BY DECEMBER I5, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLIS�IMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUII'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF AEEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQ E A SITE PLAN.
DATE: It-�- (O SIGNATURE:
PRINT NAME&TITLE: 00 {�� • DIllS
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11/16/2010 10:26 fAX 5085635587 MURRAVSMACDONALD �007/001
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nit9 CERnFlCaTH�S ISSUED i48 a MA77ER OF INFpRMATON ONLY AN� CONFERS NO RIGNTS uPON niE CERTIFICATE MOLOER.TXIS '
CERTIFICATE DOES NOi AFFIRAAATNELY OR NEGATIVELY AMEND, EX1'END OR ALTER 7wE COVERAGE AFFORDED BY tMe rOUCIEB '
BELOW. 7FIIS CERitFICATE OF INSURANCE DOES NOT CONSTTUTE A CONTRACT BE7VYEEN TNE ISSUINO INBURER($), AUTHORIZED ��
REPRESEMTATIVE OR PROOUCER,qHD T�iE CE�t71FiCn7e Ho�n�R. '
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INDICATED. NOTWITH5TANDING ANY REOUIREMQdr, TERM OR CONWTION �ANY CANTRACT OR OTHER DOCUMENT WITH RE3PECT TO WNldi TI96 '�.
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RTIFIGA7fi OL�R NCEILATON
(SOB)398-0836 &IOULD AN�OF TNE AeOVE GESCRIBEY POLICIES 9E CANCELLED 6EFORE
TME EXPIRATION DATE TMEREOF, NOiILE WILL BE DELIVEREO N
Tova of Yasmouth ACCOROANCE wRX TXE POI.ICY PROVISIONS.
1146 Route 2B
BouEh Yarmauth, I4A 02fi64 �M°�°"E""Es�NT�mE
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ACORD Z5(ZDU9I09) �79B8-ZOOB ACORG CORPORATION. All riphls rasarved.
IN8o26��uoeoe� The ACORD name and logo aro regisfared marks M ACORD