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���a � TOWN OF YARMOUTH BOARD OF HEALTH N��� � � �!�f 1
APPLICATION FOR LICENSE/PERNIIT -2012
' � * Please complete form and attach all necessary documents by Decem . ' D T
Failure to do so will result in the retum of your application pac , ,,(�
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ESTABLISHMENTNAME: ���'� ' 1 Gti1i"tTAXID•
LOCATION ADDRESS:N ' TEL.#: 7�/
MAILING ADDRE S:
OWNERNAME: � 0.� '� P O P(�C (,�
CORPORATION NAME(��IF�PPLI_CABLE): L_O�_ �- C •
MANAGER'S NAME: C•L�S"VLQ:(�Y1Q C,l TEL.#: . Cp q
MAII.ING ADDRESS: (o
PO�.CERTIFICATIONS: i
The pooCsu�erYisor must be certified as a Pool Operator,as required by State law. Pleas�lisftlie designated
Pool Operator(s) and�ttar)1_a oopy of the certification to this form. —'
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Pool operators must list a minimum of two employees c certified in basic water safety, standard First Aid
and Community Cazdiopulmonary Resuscitation (�PA). Please i se employees below and attach copies of
employee certifications to this form. The �Ieal�h Department will no ast years' rewrds. You must
provide new copies and maintain a�'ile'at your place of business.
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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 ffie at your establishment.
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PER ON IN CHARGE:_
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 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 file at your place of business.
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RESTAURANT SEATING: TOTAL# I I�
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SWIMMINGPOOL $SOea.
_LODGE $55 _TRAILERPARK $105 _WHIRLpOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100SEATS $85 _CON7'INENTAL $35 _NON-PROFIT $30
�>100SEATS $160 �IZ'OU�] 1COMMONVIC. $60 ��Z— 0 _WHOLESALE $80
RETAIL SERVICE: —RE3ID.KI'['CHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FE8 PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.fr. $225 _VENDING-FOOD $25
_Q5,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95
NAME CHANGE: $15 AMOLINT DLJE _ $ 22 0 , o0
�***'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 M[JST BE COMPLETED ANB SIGNED, OA
CERT. OF INSLJRANCE ATTACHED
OR
WORKER'S COMI'. AFFIBAVIT 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
M01'ELS �:11ID QTFIER LODGg\TG%uTAP,I,ISI�.IENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be
limited to the temporary and short term occupancy,ordinarily and customazily 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 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
prior to opening.PL,EASE 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 standard 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 OPENIlVG:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspection ttuee (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yannouth must notify the Yarmouth Health Department by filing the
requued 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.vannouth.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 Departrnent. Fail�re to do so will result in the suspension or revocation of your Frozen
Dessert Permit until the above terms have been met.
OUTSIDE CAFES:
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OUTDOOR COOKING:
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 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S) BY DECEMBER 15, 2011.
Ai T 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 REQ E A SITE PLA .
DATE: SIGNATURE: �� r��J`%�
PRINTNAME &TITLE:�('i--f Pt'Ib� �I nQv�IG (,t,�)'}�� �/���
Rev. 10/25/11
11/63/2011 14: 56 761444�09� ROC�API INSURH��k:E AG PAGE a2/02
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