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Home My WebLink AboutApplication and WC �ti� � . TOWN OF YARMOUTH BOARD OF HEALTH G3`+��CiO�7I�� ' �� APPLICATION FOR LICENSEF� , �/ �� - _;"� NQV 'i 9�U15 '"' * Please complete form and attach all necessa�y-do�'�m , �ec"' ber I S 201 Failure to do so will result in the return of}�u�:�p�sliea p cket�.�EqL7H DEPT. ESTABLISHMENT NAME: '+ T ID: LOCATIONADDRESS: ( (0� ROcfYe. r6 � JZ'+i Ya�.n�h, h,V{asc��'EL.#: �b�s•39N-O�'9'7 MAILING ADDRESS: �o N.� E-MAIL ADDRESS: •'�o vn OWNER NAME: 2►,c- CORPORATION NA �F APPLICABLE): �'ct �e ��' MANAGER'S NAME: �J ( TEL.#: MAILING ADDRESS:� 1 O C orrrr �Ss �a�*r►1 �'la rmorrti, /YI�I 02(oG,LI POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State►aw. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. _ 1. — -- 2. _ Pool operators must list a minimum of two employees currently certified in 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 £le at your place of business. 1. 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. 1. ��w a roQ �Ct,,S Yl 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �- i �.Pat�� ci 0. �-Ua,�� a.�lar+�es � C�l� �,o►a ALLERGEN CERTIFICATIONS: All food service establishments 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 HeaUh Department will not use past years' records. You must provide new copies and maintain a file at your establishment. t. _Fn�Pwa,r� �.lk�,�al� 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. 1. �(�- ` � 2. 3. � o- 4. RESTAURANT SEATING: TOTAL Z5 d � 5��, �D OFFICE USE ONLY __ 1.DDrIN(:• --—________— _____ ___ _.—_____._._ - . . . __ _.. — .___ ..____—_._.__—__——___ .__ ___. - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# Ti&B $55 CABIN $55 � MOTEL $ll0 INN $55 � CAMP $55 SWIMMING POOL$ll0ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQU[RED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k �0-100 SEATS $125 6�OZA CONTINENTAL $35 NON-PROFIT $30' , >100 SEATS $200 �COMMON VIC. $60 ��1 WHOLESALE $80 —RESfD.KITCHEN $SO � RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 Q5,000sq.Yj. $150 _FROZENDESSERT $40 _TOBACCO $t10 � NAMECHANGE: $15 AMOUNTDUE _ $ lBS. 00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****�.� - -• F�R�,,,��e,,,�� a� .:,a .,.�@i�iL �- I 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 OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces 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 ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short terxn 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 aze 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 establislunents 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 Yannouth Health Deparhnent 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 Deparhnent, 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 revocadon 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 ar food service establishxnent is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR I�ESgONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. 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 REQUIRE A SITE PLAN. DATE: t !`1 �5 SIGNATU : w�� PR1NT NAME& TITLE: �Q"f r� c-� a wA.I�� 1a,nQ�.Q � , Rev. 10/O1/IS � ll/19/2015 13:01 Brytlen and Sullivan Kristyn Downer�Cape Deli 1/1 -�'1 PICCA-1 OPID: KD '`�`c,,.��R� CERTIFICATE OF LIABILITY INSURANCE °°'�`""'"°°"""' �v�s�zo�s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTHORI7ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subjec[to the terms and cond'rtions of the policy,certain policies may require an endorsemeM A statemeM on this certificate does not confer rights to the certificate holder in lieu of such endorseme s � " PRODUCER �E: HyannisOffice BrydenB.SullivanlneAgency PXONE uc No:508-790-1414 88 Falmouth Road uc No e�c:508-775-6060 Hyannis,MA02601 � Hyannis Oifice noorsess: IN9URER�3)�FORDING COVERAGE WJC f INSURER A:G U2fd�fISU�2110E G fOU P MSURED CapeDeliFootls,lnc.dba . �r,suaens: 1105 Main Street South Yarm outh,MA 02664 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: iHIS IS TO CERTIFY TFIAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO hIE INSURE� NAMED ABOVE FOR THE POLICY�PERIOD INDICATED. NONdITHSTANDING MIV RE�UIREMEM, TERM OR CONDITION OF ANV CONTRACT OR OiHER DOCUMEM WIiH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS, EJ(CLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. �LTR TYPE OF INSURRNCE g POLICV NUMBER MMID MMN LIMrtS COMMERCIq�GENERAL LIABILITY EqCH OCCURRENCE $ CLA�MS-IvNDE �OCCl1R PREMISES Ea occurrence) S MED EaP(My one peaan) $ PERSONNL&ADV INJURV $ � 6ENLAGGREGATELIMITAPPLIESPER�. GENERFLHG6REGATE $ � POLICY �jEo- �LOC PRODUCTS-COMP/OPAGG $ � OTHER $ AUTOMOBILE LIABILffV COMBINED SINGLE LIMIT $ EeacdtleM) ANYAlJrO BODILYINJURY(Perperson) $ � ALLOWNED SCHEDULED BODILVINJURY(Peraccieem) $ � AUTOS AlIT05 NON-OWNED HIREDAUTOS q�pg - PereccitleM) $ $ UMBRELLALIAB OCCUR FACHOCCURRENCE $ EXCESSLIAB CLAIMSMHDE AGGREGATE $ � . DED RETEMION $ g WORKERSCOMPENSATON � P AND EMPLOYERS'LIABILffY STATUlE ER A ANYPROPPoEfOR/PARTNERIEXECIfiIVE ��N CAWC601931 08/01/2015 08/01/2016 E.LEACHACCIDEM $ $OO�OO OFFlCERIMEMBEREX0.UDED9 N❑ N�A (ManE#oryinNX) EL.DISEASE-EAEMPLOYEE $ SOO�OO �ESCRIPTION OP OPERATIONS below E L.DISEPSE-POLICY LIMIT $ SOO�OO DESCRIPTION OF OPERATONS)LOCA110NS/VEHICLES (ACORD 101,AdEMlonal Ramarka Schetlule,mry be akacheE H more space Ie nquintl� CERTIFICATE HOLDER CANCELLATION YARMOUT SNOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE TNE E%PIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Town of Yarm outh ACCORDANCE WITH THE POLICV PROVISIONS. � 7146 Rt 28 SouthYa�mouth,MA02664 A�ORIIE�REPRESEMATIVE � Hyannis Office O 1968-2074 ACORD CORPORATION. All rights reserved. . ACORD 25(2074/Ot) The ACORD name and logo are registered marks ot ACORD