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� °' �� TOWN OF YARMOUTH BOARD OF HEALTH
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, APPLICATION FOR LICENSE/PERMIT-ypl 1��� '; 'a DEC 14 2010
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* Please complete form and attach all necessary documetrts by ecemb '15 2010
Failure to do so will result in the return of yopr ap�glied'hon pack t.���� s � ��-'�
ESTABLISHMENT NAME: /�S,i�� �rz�:5 Lu wv-f- {�� �.�on_5` TAX ID:
LOCATION ADDRESS: cl 31 �fE 2 8 �S`,�• .on�cw�-N� f>1,o �.� . TEL #� �oB - �bo -Sy9 y
MAILING ADDRESS: sA„���
OWNERNAME: �� MON� L � L��zo�
CORPORATION NAME (IF APPLIC BLE):1�q S,S �{ S J�:rZ��s co.>v-}� ��6?u.on-5 T.�.e -
MANAGER'S NAME: TEL #� �bg -7 � -4 q g
MAILING ADDRESS: _ SAm �
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 forni.
1. 2.
Pool operators must list a minimum of two empioyees currently certified in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
certifications to this form. The Health Department will not use past y�ears' records. You must provide new
copies and maintain a tile at y�our place of business.
1. 2
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establislunents are required to have at least one full-tane employee who is certified as a Food
Protecrion Manager, as defined in the State Sanitazy Code for Food Seivice Establislunents, 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 y�our estabiishment.
l. 2.
PERSON IN CHARGE:
Eacli food estabuslunent must have at least oue Person In Cliaree (PIC j on site durmg hours of operation.
L 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 tnnes. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this foim. The Health Department will not use past years' records.
You must provide new copies and maintain � file at your place of business.
1. Z
3- 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGL\G:
LICENSE REQUIRED FEE PERMIr# LICENSE REQUIRED FEE PER\4Ii= LICENSE REQL�IRED FEE PER'�IIT=
_B&B 555 _CABIN S55 _MOTEL S55
_�`+N S55 _CAMP S55 _S4i7vL�41NGPOOL S80ea.
_LODGE SSi _TRpII,ERPARK 5105 � !�b'IIIgI,pOpL 580ea.
FOOD SER�'ICE:
LICENSEREQUIRED FEE PER'�fII'= LICENSEREQUIRED FEE PER'�Ili= L[CENSEREQUIRED FEE PE&YIII'#
_0-100 SEA'IS S85 _CONTINENTAL S35 _NON-PROFIi S30
_>I00 SEATS 5160 _COMt�fON VIC. S60 _�i�'HOLESALE S80
RET�IIL SER�7CE: _RESID.KIiCHEN 580
LICENSE REQUIRED FEE PER'�fIT# LICENSE REQUIRED FEE PER�fIT# LICENSE REQUIRED FEE PERI�III'�
�<SOsq.R. S50 �I�''dy� _»S,OOOsq.ff. S2?5 _VENDING-FOOD S25
_a25,000 sq.Ti. S80 _FROZEN DESSERT S40 I iOBACCO 555 _����
sa�ctr.��cE: sis AMOUNT DUE _ � I o5•Oo
**""*PLEASE TLR\OVER A\D CO3IPLETE OiHER SIDE OF FOR�I"****
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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 Inswance. '1'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVTP MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING F.STABLISHMENTS
TRANSIENT OCCUPANCl': For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy shall be
]imited 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 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 haue been closed for the season must be inspected
by the Health Depaztment prior to opening. Contact the Health Department to schedule the inspection three(3)days
pnor to opening. PLEASE NOTE: People aze 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.
P��L CLOSING: Every outdoor in ground swimming pooi must be drained or covered within seve�(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 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.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 results
submitted to the Health Department. Failure to do so will result m the suspension or revocation of your Frozen
Dessert Permit until the above terms haue been met.
OUTSIDE CAFES:
Outside cafes(i.e., outdoor seating with waiter/waitress service);must have nrior approvat fromthe Board ofHealth.
OUTDOOR COOHING:
Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Permits nxn annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS M Q IRE A SITE PLAN.
DATE: I 2— l�1 — 1 c� SIGNAT - ��
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