The URL can be used to link to this page

Home My WebLink AboutApplication and WC 5 � � TOWN OF YARMOUTH BOARD OF HEALTH G3(�(�[��/G oD APPLICATION FOR LICENSE/�ERMI�-- 6 nv t � * Please complete form and attach all necessary docuri7��D e be�lS ��5:�15 Failure to do so will result in the return of y�ur-appli�txon p etH�LTM DEPT. ESTABLISHMENT NAME: S rt� AX ID: LOCATION ADDRESS: /7 �J Tq-�+n 1 r n Y' S �Gr vh E-�► VG�A TEL.#: $k 34 '�SS� M.aiL�rrG aDD�ss: . d�l� 3 �� c i�vy E-MAILADDRESS: hu✓� • x6�, � +"� OWNER NAME: K P:F r`�, � � �- CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: .�a hG�t'U !�� C�C via n v1 , TEL.#: '�;Ff ",34 ' �S� MAILINGADDRESS: �W�P �� 4 V't- POOL CERTIFICATIONS: The pool supervisor must be certiCed 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. - 1 -- — —--- _ . _ � --- — - 7-- - - - -- Pool operators must list a minimum of two employees currently certified in standazd First Aid and Community Cazdiopulmonary 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. Z• 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. 1h�MGs �-� IIr `c 2. R�GV� �G'rG, PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. i. �cr�45 �elivi -t . 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 file at your establishment. 1. �I'l�M G 9 ��t I 1 n -c 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 SGn�lrt� OI G � C�un.� � 2 3. 4. RESTAURANT SEATING: TOTAL# -- - OFF�CE�i .,,... �� v�.,��- __ -- -- ----- -- ----- LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTAED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $I10 INN $55 —CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 �S �COMMON V[C. $60 �J-� _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 . _<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ 260� OO � *****pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION � Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or per�nit 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 tases 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 inspecNon 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 standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereaf[er. 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 Deparhnent 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.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 ofHealth. 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 3 L 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: PRINT NAME & TITLE: Rev.10/Ol/IS . ��'� SKP1 M-1 OP ID:AL . '`�� CERTIFICATE OF LIABILITY INSURANCE °;a�15' THIS CER'TiFlCATE IS ISSUED AS A MATIER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA7E HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATiVELY OR NECaATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETMEEN THE ISSUING INSURER(3), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TNE CERTIFlCATE HOIDER. IMPORTANT: If ttre cerdfieate holcbr is an ADDtT10NAL INSURED,the poliry{i�]must be endorsed. N SUBROGATION IS WAIVED.subJeU to Me Oerms and eonditions M the poliey,ceRain policiss may require an�tlorsement A statement on this eeRiflcate tloes not eoMer righis to the cwtificate hdd�In lieu of such end s. PROD��` xnu�; DGP-Miles Insurance A ,Inc. DGP-Miks Insuranee Agency,inc 3 School Sh�et P.O.Box 1018 °� 508-824-8�1 M, 508-880-2734 Tauntwi,MA 02780-0967 � Gordon G.Asack . noonEss: . S AFFORG�IGCOYERAOE NAICB pl6URERp;TECt1f10� �f18.CO. /�M��J$ iasunEo SKP1M.LLC dbe Ski�y's Pier 1 maupER e: 731 INain SL dba 7avem 731 277 S Shore Drive LLC dba Surt �°� '8 Sa�Motel - pwunEx o: Sa�MMra DI Giovanni P.O.Box 370 ��*E' SYa�nouth MA02664 rsuneeF: COVERAGES CERTffICATE NUMBER: REYISION NUTABER: 7HI5 IS TO CERTIFY THAT THE POIJCIES OF INSURANCE LIS7E0 BELOW MAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE POIi THE POLICY PERIOD INDICATED. NOIWITHSTANqNG ANY REqUIREMENT, TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS CERTIFICATE MAY 8E I55UED OR MHY PERTAW, THE INSUR4NCE AFFORDED BY THE POLICIES �SCRIBEO HERE7N IS SUBJECT TO AL�THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS SHOWN MAY HAVE BEEN REWCED BY PAI�CLAIMS. l7� TYPEOFMStMIVICE POtACYNIpABER 111YT3 Gd6NLLu�NiY EAGIOCCIIRRENCE S C�MERCVLLC�lERAI.LVHLrtY 6aavm¢e S CWMSaAaDE ❑OCCWi 0.EDE%P(MYoneperean S PERSONpLBADVINJURY S GENERALAGGREGn7E S GEHL�G4REGI17EL91RAPPl1ESPER: PRODUCTS-COMPlOPAGG S POLICY P� LOG E AUTO�AO�LE 1J1186JiY ��9 l�Afi N!Y MlfO BOUILV RUURY(Per Gsaon) 8 AU�'I'OS�� 5�� BODILYW.IURYWmao� S FtlR�AUf03 p�p� PERACC�E S �� 5 INIBREl1ALinB OCGIAt EACHOCCURRENCE S . EIIGESSlY18 IXAWS�MADE AGC.REGATE $ I DEO RE7ENTIONS ' Y I NWRI�IffiC0�71M! WCSTATU- OTN- i AND EMPLOYERS 1L181L1fY A ANYPROPFtETOR�PARRJEP/EXECUfIVEY/N C�GSO7II OS/3O/YO'IS OSI3O/YD'IB E.LEACHACCbEM S 'IOO� i �FICERMFJ�Epp(0.U�Ep9 � N/0. (tl�ym, /biMN1 EL.OISEASE-ENEMPLOYE f ��. DESCRPfIONOF�ERl1T10NSEabr ELOISEASE-POLICVIWNT S �. DE$CPoPl10N OF OPEM7WX8!LOCA7qN8/1fEMCLE3(�n AWIm 10t.Atl�poml Rwoab 3GMdM.pmm�apew i��6tl) Covaragas are subject to the actual poliay texms, conditions, limitationa, dePinitions, endorsaeats and exclusions. CERTff�ATE HOLDER CANCELLATION s�wu�o an oF n�e neove oesc�o rouc�s ee cnwceu.eo seFors� Evidence of Insunnce TNE E7(PIRATION DATE THEREOF, NOTICE WILL BE DELNFRED M nccoRo�wce vwrH n�Poucr reowswNs. AV�EOREPRE8EMiA77VE 5°�-� �1988-2010 ACORD CORPORATI�1. AII rights reserved. ACORD 25(2010/65) The ACORD r��and logo are reg�tereA marks of ACORD �