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Home My WebLink AboutApplication and WCr�? TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT - 2015 EN6LeWCOO9 (tAUI COPDC * Please complete form and attach all necessary documents by Decemp'hi 594 Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: bNEtF06040 864ch Cood"i%ii t,H floacio WbAITAX ID: LOCATION ADDRESS: KO 9,?0,f:b Al, )/.,gpkn ou.'% 0 A203 TEL.#: MAILING ADDRESS: 3 9 LO/S 4,1,V5 81444fl CA H4 0 /6,2IAPR 2 3 HIS E-MAIL ADDRESS: SS R o 0 G Coeii OWNER NAME: CORPORATION NAME (IF PPLICABLE): MANAGER'S NAME: O TEL.#: 6/7-.54fg-l.S4 9 MAILING ADDRESS:�f 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 form. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. �9#wdch gjeO76 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. l._ PEF Ead 1. ALI \ All i as d,� copi pro, HEI: /Z I / ] All lVkJu bVI viuo USLUMIStuiict US wiLii I -J scars or more must nave 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. Y 1d-3 - Person In C A r' n• Lve at least c ification, Tvice Estat Ise attach ealth Dep: C� cam( (C w v�l ,�.`�, 'ou must r establish 1 3 RESTAURANT SEATING: TOTAL # LODGING: LICENSE REQUIRED FEE INN $55 LODGE $55 FOOD SERVICE: LICENSE REQUIRED FEE 0-100 SEATS $125 >100 SEATS .$200 RETAIL SERVICE: LICENSE REQUIRED FEE _<50 sqq.ft. $50 <25,000 sq. ft. $150 NAME CHANGE: $15 OFFICE USE ONLY PERMIT # LICENSE REQUIRED FEE PERMIT # CABIN $55 _CAMP $55 TRAILER PARK $105 PERMIT # LICENSE REQUIRED FEE PERMIT # _CONTINENTAL $35 COMMON VIC. $60 PERMIT # LICENSE REQUIRED FEE PERMIT # >25,000 sq.ft. $285 _ FROZEN DESSERT $40 LICENSE REQUIRED FEE PERMIT # MOTEL $110 SWIMMING POOL $11Oea. �p WHIRLPOOL $11Oea. LICENSE REQUIRED FEE PERMIT # _NON-PROFIT $30 WHOLESALE $80 —RESID. KITCHEN $80 LICENSE REQUIRED FEE PERMIT # VENDING -FOOD $25 _TOBACCO $110 AMOUNT DUE = $ t k 0. 00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE 0ll� 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 v 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 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 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. PLEASE NOTE: People are NOT allowed to sit in 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 inspected by the Health Department prior to opening. Please contact the Health Department 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.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 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 from the Board of Health. 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 REQUIRED FEE(S) BY DECEMBER 15, 2014. 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 REWIREA SITE SAN. DATE: 4`-A �L SIGNATURE: PRINT NAME & TITLE: Rev. 11/03/14 (f�odC-4 A�� CERTIFICATE OF LIABILITY INSURANCE °��,""a°"Y""' THIS CERTIFlCATE IS ISSUED AS A IiATTER OF MFORNATION ONLY AND CONFERS WO RIGHiS UPON THE CERf1FlCATE HOLDER.THIS � CERTiFlCATE D�S NOT AFFlRMAT1yELY OR NEGATNEIY AMEND.IXIEND OR ALTER THE COVERAGE AFFORpm BY THE POLICIES BELOW.THIS CERTIFlCATE�1NSURANCE DOE8 NOT CONS7iTUTE A CONTRACT BE7NIEEN TNE ISBUING INSURER(8j,AUTHORIZED REPRESENTATNE OR PRODUCER,AND THE CER7IFICATE HOLDER IMPORTANT:H the certifiea6e holdar is an ADDRIONAL INSURED,tlie polky(i�)must 6e endorsed. B SUBROCaATWM IS WAIVED,s�jed W ttre tems a�conditions of the PoliaY.eertaln Potkies may reQuire m�endorsemeM. A statanrnt on tl�k eertidicaDe does tat to�er rights to the certiflcate holder In Ileu of sud�e s. PRODUCER CqffACT Payd�evc Insuran�Agenq Inc PAYCHEX INSURANCE AGENCY,INC. 750 SAWGRASS DRIVE P� 877-266�6850 F� . 58538&7426 ROCHESTER,NY 14G20 E�� Ccws�ycNex.com B13URER(S)AFFORdNG CAVERAGE NAIC t INSURED INSUt�t A: NorGUARD Insurance Cqnpany 31470 HEAVENLY POOLS INC. �N��B. 119 POND VIEW DRNE CENTERVILLE,MA 02632 ��; INSURER D: � NiS11REfZ E INSIIRER F: COVERAGES CER'TIPICATE NUMBER: REVISIpN NUMBER: nns�s ro�enFv-n�wrrrE roucaEs�msuwwcE usrEo eaow rwvE e�issum 1n rr�iN�Na�n naovE r�ax ng roucr a�xan INOICA7ID.NOTVYRHSiMlDINGANY REWIREMENT.iERA/OR CONDfiION OF ANY CON(RACT OR OTHER OOCUAIENT WRH RESPECrTO WHICH THIS CER7IFICATE MAY BE ISSUED qt MAY PERTAi�I. INSURlWCE AFFORDm BY THE POUC�S�SCRIBED HEREIN IS SU&IECT70 ALL THE TIItMS. IXCLUSIONS AND COND(TIONS OF SUCH POLICI SHONM MAY HAYE BEEN REDUCED BY PAID CLAIMS. � ivFE�wsURANCE - POLICY1p11�ER roucrrfF vouGro� �gsRs GaIERAL i.lABil.l'IY E�CNOCCURf�FMCE f cor.v�c.w,�.c`.e-,��mn��uani.rv . .x:: �ro� s ��"�'9�^� ,, . . .. 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CERTIFlCATE HOLDER CANCELLATION ENGLEWOOD BEACH RESORT s'wu�o an oFn�neove oescwem vouaes ee uncox�e�nf om�winoN 60 BROADWAY ow�n�.xm�c¢p�ay eE pgrv�m�p�w�p�E y�.�pp�y WESTYARMOUTH.MA 0�73 rrtar�.eurFnAu�mw�asucx�or�s�wu�rooeuwnp/a� W&lffYOFApY IOfW UPoN"f!H COYPANY.fBAfiBlISOR 1�Sp1TATNES AUIHOR�D REPRESEMATVE ACORD 25(2010/0� � �1966-2010 ACORD CORPORAl10M. NI rigMs reserved. The ACORD name and logo aro regisEered marks of ACORD ��