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Home My WebLink AboutApplication and WC ' � TOWN OF YARMOUTH BOARD OF HEALTI� � �� APPLICATION FOR LICENS�/PERMI'�-�2b1� �QV L 3 ZU15 / * Please complete form and attach all neces��ry dqcuments Dece ber IS 2015. Failure to do so will result in the return of your applicarion p ckeH EPT. ESTABLISHMENT NAME: TAX ID: - LOCATION ADDRESS: TEL.#: - MAILING ADDRESS: 0 E-MAIL ADDRESS: C �77C = OWNER NAME: �t CORPORATION NAME (IF �'PLI B ): MANAGER'S NAME: /�- 1d "'+ b 1A�A a Ka TEL.#: �;jZs( -�(� -ss�� MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatar(s) and attach a copy of the certification to this form. �— -- - _ _ __ --- ---�— -___ 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 Cle at your place of business. L 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 Hea►th 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. DOSP✓p�� G P l/��/� 2. ALLERGEN CERTIFICATIONS: All food service establishments are 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' records. You must provide new copies and maintain a 61e at your establishment. 1. 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. i.� �c�� ,V�i7�y�. �,o_ 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PEAMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: � LICENSE REQUIRED FEE P tT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $I25 � 6-6Z?j CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �WMMON VIC. $60 _(6.,�Z _WHOLESALE $80 —RESID.KITCHEN $80 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 =<25,OOOsq.ft. $I50 _FROZENDESSERT $40 TOBACW $I10 NAME CHANGE: $15 AMOUNT DUE _ $ I$5.DO . *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**** - . . G ADMINISTRATION � I I Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i 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 I OR i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ', Town of Yarmouth taxes and liens must be paid p 'or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: I YES NO f f MOTELS AND OTHER LODGING ESTABLISHMENTS ' TRANSIENT OCCUPANCY: For purposes of the limitations of Motel ar 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 nat more than thir[y(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 i 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 priar to opening, and quarterly thereafter. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of f 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 � obtamed at the Health Department,or from the Town's website at www.varmouth.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. i OUTDOOR COOHING: Outdoar 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 3 L IT IS YOUR RESPONSIBILITY TO RETURN ' THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER I5, 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 COMME CEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I DATE: � SIGNATURE: � - ; PRINT NAME & TITLE: �Id 6 �` ��C bll,( � I Rev.10/01/15 I, /� INAHO-1 OP ID: DS s�►CORo• CERTIFICATE OF LIABILITY INSURANCE °"'�,M"�°°"�'"' `.� �vzs�zo�s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELV OR NEGATIVELY 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�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy�ies) must be entloBetl. If SUBROGATION IS WAIVED,subjeet to the terms and eondkions of the policy,cerfain policies may require an endorsement. A sfatement on this eertifieate does not eonfer rights to the certificate holder In IMu of such endo'sement s. PRODUCER CONTACT H annis Office Bryden 8 Sullivan Ins Agency PHONE Fnx 88 Falmouth Road N, E�a:508-775-6060 Aic No:508-780-1414 Hyannis,MA 02601 E-MAIL Hyannis Office AOORE55: INSURERS AFFORDINGCOVERAGE NAICtl INSURERA:TI12 H2RfOfd z2.35� INSURED Inaho-JapaneseRestaurant INSURERB: 157 Route 6a Yartnouthport,MA 02675 INSURERC: INSUkER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTMTHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPEOFINSUMNCE � � POLICYNUMBER M��pYEFF MM�ICYE%P uMITS COMMERCIALpENERALLL1BR17T EqCHOCCURRENCE $ CL41MS-MADE �OCCUR OAMA ET R NT PREMISES Eaoccurtence 3 MEDE%P(Anyonepersan) $ PERSONALBADVINJURV $ GEN'LAGGREGATE�IMITAPPLIESPER: GENERALAGGREGATE $ POLICV�jE�a �LOC PRODUCTS-COMP/OPAGG $ OTHER: E AUTOMOBILE LIABIIJTY COMBINED SINGLE LIMIT E Ea aaitlant ANV AUTO BODILV INJURV(Pe�peroon) $ ALLOYVNED SCHEOULED BODILVINJURV�Pe�acdtlenQ $ AUTOS AUTOS HIREDAUT0.5 AON�WNEO pq�uitlenDAMAGE s S UMBRELLALIAB p�CUR EACHOCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ g WORKERSCOMPENSATON PER OTH- ANDEMPLOYERS'LIABILITY STATUTE ER A ANVPROPRIETOR/PARTNERIE)(ECUTIVE r�N OBWECIS3OES 05/02I2075 05/0212016 E.LEACHACCIOENT $ �OO�OO OFFICEWMEMBEREXCLUDED9 �N�A (Ma^tlrt°^��^NX) E.L.pISEASE-EAEMPLOYE S �OO�OO ifyes,tlescnEe untler OESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICYLIMIT $ SOO�OO �ESCRIPTION OF OPERAItONS I LOCATIONS/VEXICLES(FCORD 101,AtltlRional Remarks SCMtlula,m�y bo attac�etl 1/mora apau ic requiraG) Certificate issued for insurance veriflcation CERTIFICATE HOLDER CANCELLATION YARM003 SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA710N DAlE THEREOF, NOTICE NALL BE DELIVERED IN YARMOUTH TOWN HALL ACCORDANCE WITH THE POLICV PROVISIONS. 1146 MAIN ST S.YARMOUTH,MA 02664 AUTIORIZEp REPRESENTq11VE Hyannis�ce �1988-2014 ACORD CORPORATION. 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