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Home My WebLink AboutApplication and WC► � ' TOWN OF YARMOUTH BOARD OF HEALTH ��' o lp�� ' APPLICATION FOR LICENSE/PERMIT `Zi116 " '�?i „ - � NOV �� Zt715 "'' * Please complete form and attach all necessary docum�nts byC�emb IS 2015. ' Failure to do so will result in the return of your�ppi�cation pack . HEALTH DEPT. ESTABLISHMENT NAME: ✓1 '7 AX ID: LOCATION ADDRESS: � 120��"C �8' TEL.#:�0 - "'133/ MAILING ADDRESS: �0 , 37 S.� Ur�^^�=� q d� � G` E-MAIL ADDRESS: OWNER NAME: �i 1 V�'l!i i✓1 r � �- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ryI I( hf� t� k G n r TEL.#: S a -9 G -`I a y MAILINGADDRESS: % ! YS�7� 370 S•�I/�✓N�� 14 4 y 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. — — — _ . Z _ _ - _ 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 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 £le at your establishment. t.� IChq � I �U �� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. Y�'ltChl�� cGhf 2. 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 Health Department will not use past years' records. You must paovide new copies and maintain a file 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 6mes. Please list your employees trained in anti-choking procedares below and attach copies of employee certifications to tlus form. The Health Department will not use past years' records. ' You must provide new copies and maintain a file at your place of business. �.� rn ��hU � ll< u�►c.. z. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY -- — --------- _ - ___-L .._-_-._--_-. -- _._-_. _- _ .. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$ll0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT# �0-100 SEATS $125 �IL�OZ'� —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 �_(�–�� =RES�ID.KITCHEN $80 r 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 $25 _QS,OOOsq.R .$I50 _FROZENDESSERT $40 TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ IgS.00 *****PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM**'"** , � ' �. � ADMINISTRATION a _ �, - 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 I 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 p 'or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ' YES NO I MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinazily and customarily associated with motel and hotel use. i 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 tl�iity(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 i dwelling unit shall not be considered Uansient. 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 Yazrnouth 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. 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 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: ��'�� SIGNATURE:(� PRINTNAME & TITLE�/'!G�!'G p� G'iL(.uh�I �vrGH�/`� � Rev. 10/Ol/15 i s �� SKP1M-1 OP ID:AL '`��R�� CERTIFICATE OF LIABILITY INSURANCE ;o�,�"' , iH13 CERitFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIflCATE HOLDER.THIS CERTIFICATE DOES NOT AFFlRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTtFiCpTE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER,pND THE CERTIFICATE HOLDER. IMPORTANT: tt tlie certNieate hoi�r�an ADDITIONAL INSURED,tl�e polig(ies]m�t be endorsed. H SUBROC,ATION IS WAIVED,subject to tl�e terms and conditiw�s oi tha policy,eerpin poiicies may requiro an endo�semeM. A afaEemeM a�Mis eertificate does rrot eonfar rigMs to the certlfieate holder in liau W sueh e s. DOP�Ai�insurance Age�ey,inc �uw� �+P-Mlies I�unr�ce A ,Inc. 3 Sehool SVeet P.O.Box 7018 °XO� •50&824-8961 F N, 508-880-2734 TauMai,MA OS780-0957 E� Gordon G.Asaek ' nFr•oi+oex�covEnac,E wvcs ixsu�n�:Tech Ir�.Co. AMTRU ixsurtEc SKPIM,LLCdbaSkippy'aPieri ��e: 737 Main St dba Tavem 731 277 S Shore Drive LLC d6a Surf �� '&SandMotel � �o: Sandn Di Giovanni P.O.Box 370 ��E: SYarmouth MA02664 ��R�F: COVERACaES CERTIFICATE NUYIBER; REVISION PIUMBER: THIS IS TO CERTIFY THAT THE POLIpES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FM2 THE POLICY PERIOD INDICATEO. NOTWfiHSTAlHMNG ANY REqUIREYEKT, TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WfIH RESPECT TO WHICH THIS CERTIFICATE MqY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IXCLUSIONS AND CONDRIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PNO CLAIMS. L7R TYFEOFNBUMNCE POGICYNUIBER LIItliS OENBfNLLNBWJIY FACMOCCURRENCE S conv,eeacw.c�+n��weiurv ��.,,�,L s cwMs.wwe ❑xcun e,Eo�crtnroa»v�l a vensowuaaovw.n�ar s cer�nunccnecn� s GENLAG/3RECr1TElL1RAPPlIESPER PROOUCIS-COI.PlOPAGG S POLICV PR0. 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CERTIFICATE HOLDER CANCELLATION BNOUID ANY OF TNE ABOVE DESCRIBED Pa1pE$BE CANCELLED BEFORE EVidBI1Ce Of 111SUPd(IC6 T� �IRAl70N DA7E TFEREOF, NOTICE WILL BE DELNERED M ACCORDANCE W(TH TNE ppLlCy pRpy�5lpNg, AIIT W R�LD RnFPRE�S@lTAII VE VaSL..f�.} . \ \ o�sae-zo�o ncoeo cor�orsnr�. ai�9n�s�er�a. ACORD ZS(201 W05) The ACORD name and logo are regfstered marks of ACORD �