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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH a�6l�OMLsDD , �� + APPLICATION FOR LICENSE/PERM,I.T,- ^ NOV ' �: : ��'" � 0 2015 `� * Please complete form and attach all necessary.dodurnent�by Dece er IS ZO15. ',, Failure to do so will result in the ret�ni of y�our,applicatron pa ket.HEqLTH DEPT. ESTABLISHMENT NAME: e i+l�+ Cs�Lit.w T,� • �, LOCATION ADDRESS: �7 U Z{"Q. � EF TEL.#: S�fS 3�Z SU 0`P MAILINGADDRESS: ��F ot.k4 � Se 1 c� QnrK� S Mn- t�7.�3? E-MAILADDRESS: � `i4��5 C� <Shecp b . COP'� . OWNER NAME: C.sh CORPORATION NAME (IF APPLICABLE): ,<�n,Ke� � (-ihcl+S .�'N c MANAGER'S NAME: ('� rlpr (Je�k�ertie TEL#• ,i f, MAILING ADDRESS: - 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. i — __ . _ --- ' 1. ------ _ Z.- - Pool operators must list a minimum of two employees currently certified in standard 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. 2. I 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. �, ��2c+.� 1..� e1Lv�1Y � 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � 1. �l�s-�cS' W C� St L 2. ��L l� �CI.Wl.�O �N UN�� I s 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 far 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. Z 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. �Z�.�c,�'�- L u Z c�.c.� 2 3. Zl u��c_, t-+-ccA,r 4. RESTAURANT SEATING: TOTAL # — -_ _ -- _ nFFirF Irq rnvr v LODGING: � ---.--._� LICENSE REQUIRED FEE . PERMIT# L(CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B CAB[N —�� $55 _ $55 . MOTEL . $110 LODGE $55 _CAMP SWIMMING POOL$110ea. _ $55 _TRAILERPARK $$OS _WHIRLPOOL $110ea � FOOD SERVICE: LICENSE REQUIRED FEE PE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LO-IOOSEATS $125 �r]�'�z� CONTINENTAL $35 _>100 SEATS $200 j COMMON VIC. $60 NON-PROFIT $30 �, ��J _WHOLESALE $80 ��. RETAIL SERVICE: —RESID.KtTCHEN $80 �' 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 $I10 rvnme canrvce: $is AMOUNT DUE _ $ I$5',o0 "****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I I i : . . i ADMINISTRATION ' i 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 taxes and liens must be paid pri r to renewal or issuance of your permits. PLEASE CHECK II APPROPRIATELY IF PAID: YES � NO � 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,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 withip any six(6)month period. Use of a guest unit as a residence or ' dwelling unit sha11 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 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 DeparUnent. 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 Board of Health. OUTDOOR COOHING: � Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. � f 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. ; 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 COMMEN EMENT. RENOVATIONS MAY QUIRE A S T P� ' � DATE: f� 3U � SIGNATURE:- .��Gi PRINT NAME & TIT�E: � � • Li �S r,cJ Rev. 10/01/IS ,�', JAMES-2 OP ID: DS ,a►co�zo� CERTIFICATE OF LIABILITY INSURANCE °°�`M�°"'"Y' `.i ��iao�zo�s � THIS_CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS -CERTIFICATE DOES NOT AFFlRMATNELY 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(5), AUTHOR�D REPRESENTATNEORPRODUCER,ANDTHECERTIFICATEHOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATON IS WANED, subject to the tertns and conditions of the policy,oertain policias may requira an endorsemeM. A statement on this certificate does not conTer rigMs to the certi£cateholderinlieuofsuchendorsemen s. PRo�UCER coNTaCT Bryden&SullivanlnsAgency PwamEE HyannisOffice BBFalmouthRoad ,. ac No �:508-775-6060 nrc No:508-790-1414 Hyannis,MA02607 anors�ss: HyannisOffice INSURER�S�AFFORDINGCOVERAGE riac: iNsu�a:The Hartford 22357 INSURED JamesA.Liadis,Inc.DBA wsuaEae:WesternWorld Black Sheep Bah&Grill iNsua�ac:Mount Vernon Fire Ins Co 84 Rocky Ridge Road Dennis,MA 02636 INSURERD: INSURH2 E: INSURH2F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT TNE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO lHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTNIhISTANDING ANY REQUIREMEIYi, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH hil5 CERTIFICATE MAY BE ISSUEO OR MAY PERTAIld, hIE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LIMRS SHOWN MAY H4VE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE POLICY NUMBER MAVD MAI�D �� B X COh4AERCIALGENERFLLNBIL[iY EqCHOCCURRENCE E ��OQ��O CLAIMSM4DE �occut NPP1402890 02125/2015 02/25/2016 p��ISES(Eeoccurten_e E 50,00 rv��E:P(any orn oerson� S 1,00 X LIQUO�LIBbIII�Y P�RSON4L&PD\'INJJRY 8 t,000,000 GENLAGGREGA'fELIMITPPPLIESPER GEWER.YHGGaE6^.TE 5 Z�OOO�OOO X POLICV �jE� �LOC P70DJCT5-COMP/OP.4GG $ 'I�OOO.00O OIHER' s AUTOMOBILE LIABILRY COMI9INED SINGL LIMIT $ (Ea sccitleM PNYAlfrO BJDILVINJURY(Perpereon) $ PLLOVJIJED SCF�DULED BJCIL`!INJURY(PerBtcitleM� $ HRWAUTOS �SWNED Perzsi_en;�a� $ $ UMBRELLALIAB Q�� Ea�M?JCURRENCE $ E%CESSLIAB CL41MSM4DE .4��REGFiE S Dm REfEMION $ 8 WORKERS COMPBJSq710N ANDENPLOYER6'LIABILRV STSTJic I� A 0 FICRERIMEMBERIXQUDEwD� C�� v� Nlp $WECC��$� 0310812015 03I06/2016 cL EP.CNACCID=M $ $��0�� (MentlatorybNH) El.DIE:ASE-FAEMPLOYEE $ SOO�OOO If ye5,descnbe wtler DESCRIPTIqJOFOPER4T10NSUelwv EL DISESSE-POUCYLIMR S SOO�OO C MountVemon CL2636977B 02I25/2015 02125/2015 Liquor OESCRIPTON OF OPERATONS I LOCAl10N5/VEHILLES (ALORp 101�AtlGlllonel RemarMs Schedule,may be site<heG If mon apece is nquirctl) Certificate i ssu ed for i nsurance verification. LiquorLiability limits$1000K PerPerson; $100UK PerAccident;$2000K ggregate CERTIFICATE HOLDER CANCELLATION YARM003 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TFff EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN YARMOUTH TOWN HALL ACCORDANLE WITkl TFIE POLJCY PROVISIONS. 7146 MAIN ST q�'ry�pq�D REPRESEMATNE S.YARMOUTH,MA 02664 Hyannis Office 81988-2014 ACORD CORPORA710N. All rights reserved. . ACORD 25(2014/01) Tbe ACORD name and logo are regislered marks of ACORD