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Home My WebLink AboutApplication and WC �� a TOWN OF YARMOUTH BOARD OF HEALTH ��6�� ° �� APPLICATION FOR LICENSE/PE "-- , � . � ��NOV 2 0 2015 * Please complete form and attach all necessary ocum¢'n�� ce ber IS 2015. Failure to do so will result in the return o your appi'r�aitbn ji c e LTH DEPT. ESTABLISHMENT NAME: � � S G' TOi2.� T � / LocATiorraDD�ss: SS �ciT� � U�E�'T YRRMDU�-I TEL.#: SoTr ��S O(o// MAILING ADDRESS: ��4M � E-MAIL ADDRESS: NF_ /'� L )UC>NT S�//�lTv - �' OWNERNAME: N�2YC. JI�NNSoN �GF� £N CORPORATION NAME (IF APPLICABLE): TWlLI("s-HT SC7/L/l S �NG • MANAGER'S NAME: NF L O SON M� C � TEL.#: 17 MAILINGADDRESS: 3/ LL�/ �l� LAN� ��NNiSPDRT MA D,�(�3c1 V —� 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 standazd 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. 1. 2. 3. 4. 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 file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: ' All food service establistunents aze required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' recards. You must provide new copies and maintain a file at your establishment. 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 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. L 2. 3. 4. RESTAURANT SEATING: TOTAL# --_ — --- ---- — _��'�IC� rTc�nrri v ___ _ __ -- - - --- ------ - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUTAED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 SWIMMINGPOOL$ll0ea. _LODGE $55 =TRAILERPARK $105 WHIRLPOOL $110ea FOOD SERVICE: UCENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 � _COMMON VIC. $60 —WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I <50 sq.ft. $50 � >25,000 sy.ft. $285 VENDING-FOOD $25 �� =<25,000 sq.ft. $I50 _FROZEN DESSERT $40 �TOBACCO $I 10 NAME CHANGE: $15 AMOUNT DUE _ $ I �o O . 00 *****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 MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED� I 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,ordinazily 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 Depar[ment,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 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 Boazd of Health. OUTDOOR COOHING: 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 Ii THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. I 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�QUIRE A SITE PLAN. DATE: �l'�'U—l� SIGNATURE: C�G�� PRINT NAME & TITLE: E/°�� L NNSC/it/ �Cfb� �N /QgS��NT Rev. 10/O1/IS ' ,�+co o' CERTIFICATE OF LIABILITY INSURANCE °"TE,"�'", �� ,,,,s�2o,5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORNL4TION ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMIITNELY OR NEGATIYELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTINTE A CON7RACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICA7E HOLDER. IMPORTANT: If the ceRiTicate holder is an ADDITIONAL INSURED,the poticy(ies�must be endors�. If SUBROGA710N IS WAIVED, subjeM to the tertns and condkions of the policy,certain polieies may require an endorsement. A statemeM on this certificMe dces not confer rigMs to the certiTicate holder in lieu of such endorsemeM�s). PRODUCER NAME Wm F Borhek Insurance Agency,Inc. vtipue Fax ac No en: nrc no: 311 Plymouth SVeet EMAIL Halffaz,MA 02338 AD°R� INSURER S AFFORDING COVERAGE � NAIC# iNsunertn: MA Retail Merchants WC Grou inc. ; INSURED INSURER B: I Twilight Spirits,Inc. wsurtenc: d/b!a Becker's Package Store 55 Route 28 �NSURER D: West Yarmouth,MA 02673 iwsurs�R E: INSURER F: � COVERAGES CERTIFICATE NUMBER: 00003 REVISION NUMBER: 00001 � THIS IS TO CERTFY THAT THE POLICIES OF iNSURANCE IISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA7ED. NOTNATHSTANDING ANY REQUIREMENT,7ERM OR CANDITION OF ANY CONTRACT OR OTHER DOCUMEI�lT WI?H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, iHE INSURANCE AFFORDED BY THE POLIGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIOPS AND CANDI110NS OF SUCH POLJGES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR L UBR , POLICY EFF : POLICY EXP LTR T'�EOFINSURANGE POLICYNUMBER ' MhVD ' MMIDpYYYV lihHTS I OENERAL UA&LITY ' i � . � i EACH OCCURRENCE -8 � ;CAMMERQAL GENERAL UNBILITV I � � i AM�' PREMISES Eaoccurrence $ �r�CLAIMSMADE LJ OCWR I I i I � i MEDIXP(Myonepersan) $ I I � j PERSONAL&ADV INJURV �$ � ' I 1 i GENERALAGGREGATE �S GEN'LAGGREGATELIMIiAPPUESPER: I I I � � PRODUCTS-CAMPpPAGG �$ -�PRO- � i i POLICY� LOC � I S AUTOMOBILELIA&LITY � i � � COMBINEDSIN LELIMIT � i Ea awitlem $ IANVAUTO j I � BODILYINJURY(Porperson) S ��ALL01hNED � SCHmULED I I i � AUTOS AUTQS � i BODIIV INJURV(Per a¢itlenry S NON�OWNED PROPERTVDAMAGE �HIREDAUTOS � qUTOS I � � j erectldent '$ � j jb � I UMBRELU LIAB I i OCCUR � � � I I -EACHOCCURRENCE $ �IXCESSLUIB I~J CLAIMSMADE � ! I I AGGREGATE �$ i � i DED ' ' RETENTION$ g WORNERSCAMPENSATION � X N�STATU- OTH- -AND QAPLOYERS LIA&LITY y�N � I i i TO I R ANYPROPRIEfOR(PARTNERIIXECUTNE I i E L EACH ACQDEM $ �OO,OOO AOFFlCEFRAEMBER EXCIUDED? ❑ N�A i ,, i (MantlatoryinNX) 014000502303116 1/01/2��6 I�/��J2017 ELOISEASE-EPEMPLOV $ 7�0,0�� Ifyes�tlesaibe unEer � �ESCRIPlIONOFOPfRAiIONSbelav � t I E.LDISEASE-POLICVUMIi $ SOO,OOO I i � I i i � I i j i I j DESCRIPfION OF OPERATION51 LOGATWNS I VETII4LE5(AffiM ACAR0101,AGtlltional Remancs 3c�atlule,iF more space is requVetl) CERTIFICATE HOLDER CANCEILATION Town of Yarmouth SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SoUth Yefmouth,MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTXORIlm REPRESENTATIVE �j.�� 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks ot ACORD