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� � TOWN OF YARMOUTH BOARD OF HEALTH ^
��� APPLICATION FOR LICENSE/PERI�.IT0{Z01�1]29 r.
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�� * P lease comp lete form an d attac h a l l necessary.�`b� y'De m ber I S 2 0 1 0.
Failure to do so will result in the return of}¢`QuFap �caUo pacld�FlLTH G l�.
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ESTABLISHMENTNAME: �1 T� � � ��K�KS u n�- TAXID:
LOCATIONADDRESS: 668 �2taf� /'��i� Srt• TEL.#,: 5a$-��/����G +'�
MAILING ADDRESS:
OWNER NAME: C;-��e�f ANh �a 4
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certilied as a Pool OperAtor, as required by State law. Please list the designated
Pool O��erator(s) a�d attaeh a copy of the certiftcation to this foi7n.
1. 2.
Pool operators must list a minimwn of t�vo employees cim-ently certified in basic water safety, standard Fn•st Aid and
Community Cardiopulmonary Resuscitation(CPR). Please list tl�ese employees below a�id attach copies ofemployee
certifications to tlus foim. The Health Department �vill not use past �•ears' records. You must provide new
copies and maintain a file at your place of business.
1. 2.
3. 4. �
FOOD PROTECTION b1ANAGERS - CERTIFICATIONS:
All food service establislunents az�e requn-ed to have at least one fidl-tnne employee who is certified as a Food
Protection Manager, as defined 'ui the State Sanitaiy Code for Food Seivice Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department will not use past}�ears' records.
You must provide new copies and maintain a Gle at vour establishment.
1. 2.
PERSON IN CHARGE:
Each food establislmient must have at least one Person In Charge (PIC) on site duriue hours of operatiou.
L 2.
HEIMLICH CERTIFICATION5:
All food seivice establishments with 25 seats or more must have at least one employee u•ained 'ui the He'vnlich
Maneuver on the premises at all times. Please list your employees tranied in anti-choknig procedures below and
attach copies of employee certifications to this forni. The Health Department n�ill 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
LODGI�G:
LICENSE REQUIRED FEE PERMII '�-` LICENSE REQUIRED FEE PER�4I7= LICENSE REQUIRED FEE PERbII7=
BRB S55 CABIN 555 bSOTEL S5�
INN S5� Clu� S» SWI�L\41NGPOOL S80ea.
LODGE S55 IIiAII.ERPARK 5105 � ��'HIRI.POOL S80ea.
FOOD SER�'ICE:
LICENSERFQl?IRED FEE PER\-IIT= LICFNSEREQUIRED FEE PER\IIT= LICENSEREQUIRED FEE PER\IIT=
0-100 SEATS S35 _CONiINENIAL S35 / NON-PROFIT S30
( >100 SEATS SI60 ��'"�3 � COVI:bION VIC. S60 �(f�627 _\i�'HOLESALE S80
RET.UL SER��"ICE: —RESID.HITCIIEN S30
LICENSEREQU[RED FEE PER�SIT= LICENSEREQUIRED FEE PER\4ti= LICEVSEREQL'[RED FEE PER\iti�
_a50sq.d. S50 __>25,OOOsq.B. S'_25 _�'ENDiNG-FOOD S25
_<�5,000 sq.ft. S80 _FROZEN DESSERT Sd0 TOBACCO S55
�:��zE cKa�cE: sis ANiOUnT DUE _ � 2� ,00
""***PLEASE TtiR�O�'ER A\D CO�IPLE'IE O'IAER SIDE OF FOR\I*'*"*x
L •
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 ATTACAED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSiJRANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED U 6� ��
Town of Yazmouth 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 ofthe limitations of Motel 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 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 inspectionthree(3)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 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 OPENING:
All food service establishments must be ins�ected 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.yazmouth 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 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 fromtheBoazd ofHealth.
OUTDOOR COOKING:
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 RESPONSIBILITI'TO RETURN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOT'EL OR POOL (i.e, PAINTING, NEW
EQLTIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIUR
TO COMMENCEMENT. RENOVATIONS MAY REqUI E A SITE PLAN.
�DATE: I f' � ��I D �IGNATURE: �„r�,�� ��
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