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Home My WebLink AboutApplication and WC , Q� � � TOWN OF YARMOUTA BO�RI�,OF�IER3.'�I�, r �� APPLICATION FOR LICEN��/PERMIT-20#6 ��j I Utl: U , Z U 15 �`° * Please complete form and attach all necessary docurne�s�ece ber EPT. Failure to do so will result in the return of your application p ESTABLISHMENT NAME: < Z��nY..1'O� T ID: LOCATION ADDRESS• ��o\ S`r•P�hr. �� . S. V i>flwz�l-F TEL.#: � 3�t�1-Cc6S MAILING ADDRESS: /' � " �� E-MAIL ADDRESS: �A .Si-��Ctz W�i� � OLVNER NAME: 1M�Pf2 tl-��L L.�G"`-` CORPORATION NAME IF APPLICABLE : �� Z2 v� S�L MANAGER'S NAME: �RCl\\\ �1>C� � TEL.#:�"� q- d,�- 0l\51 MAILINGADDRESS: } �U F�n(I�Ncs��S.wn,��Z c� l�tieClu�\1� wnk- ��1 Sc PdOL 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 ' cation to this form. i — � - _ — �. � — 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 file at your place of business. L � 2. / . 3. 7 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments ue required to have at Ieast 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 $ file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishxnents aze required to have at least one full-time employee who has Allergen certification, as d�ned 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. �kQc�`��5��.n� 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. '�l�n � �t Ll.A l � --r 2. � 3. G3�l Q c�w ZLZ��•�e j 4. RESTAURANT SEATING: TOTAL # aD -- —__ nFFirF ncF nrri v____ _ __ — -- -- LODGING: � � ---� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H _B&B $55 CABIN $55 MOTEL $110 1NN $55 —CAMP $55 —SWIMMING POOL$110ea. _LODGE $55 =TRAILERPARK $105 _WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N �0-100 SEATS $125 �_(j� CONTINENTAL $35 NON-PROFIT $30 _>100SEATS $200 �COMMONVIC. $60 _�b,�Zq _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $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 _Q5,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 �� NAME CHANGE: $15 AMOUNT DUE _ $ ( SS. OO ', *'"***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF F *a3 -r- �� -..a �..;c,+l�� ,. ! ADMINISTRATION « � Under Chapter 152,Section 25C, Subsection 6,the Town of Yannouth 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 i CERT. OF INSURANCE ATTACHED ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes 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 I� TRANSIENT OCCUPANCY: For purposes of the 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. ' 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 are NOT allowed to sit in the pool azea 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 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 Yannouth must notify the Yannouth 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,ar from the Town's website at www.varmouthma.us under Health Departrnent, 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&om 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 HE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS REQUIRE A SITE P AN. DATE:� �� \ 5 SIGNATURE: PRINT NAME & TITLE: (L,��\\ ,�---i`� S Rev. 10/01/IS r � ; .aCo�2�" CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YYYY) iz�ouzois THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGNTS UPON THE CERTIFICATE HOLDER. THIS CERTIPICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TMIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflwte holder is an ADDRIONAL INSURED,the policy�ies)must be endorsed. If SUBROGATION IS WAIVED,subjeet to the terms antl eonditions of the policy,certain policles may raquire an entloroament A sfatement on this certlticate tloes not confer rights to the � certlflwte holder in Ifeu of such endorsemenNs). ' PROWCER NTACT Germani Inwrance Aqency PXONE FAX 908 Main Stme[ ee: 508 428-9194 uc uo:508 28-3068 ' 05[erville,MA 02655 E'�� 55:ce emlaniirtsu2nce.com � INSURER S�AFFORMNG COVE iNsursenn:NGM(National Grange Mutual) � INSURED INSURERB: The Grump Inc.D/B/A Sweet Toma[oes Piaa iNSURER C: '1 170 Hdlingsvorih Rd. �1 osrerville,Mn 02655 iNsursen o:NGM(National Grange Mutual) INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED. NOTMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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. INSR ADDL U6R PqJCYEFF POIJCYEXP LTR lYPEOFINSURANCE PqJ�yNUMBER MMIUDIYYYY MMIDp/YYYY I1M115 A X COMMERCVILGENERALLIqBLLATY BPT4921R 3/4/2015 3/4/2016 EACHOCCURRENCE $ 3000000 OAMAGE RENTEO ' CWMSMADE X OCCLIR PREMISES Eeatturtence S A ' X LiauorLiabiliN BPT4921R 3/4/2015 3/4/2016 MEpE%P�Anya�eperson) g PERSONALSADVINJURY E GEN'LAGGREGATELIMITAPPLIESVER: GENERALAGGREGATE $ 2,000,000 POLICV❑JE6 � LOC PRODUCTS-COMPqPAG6 S OTHER: § AUTOMOBILE LIABILIfY COMBINEO SINGLE LIMIT S Ee acdEent ANV AUTO Bp01LV INJURV(Perperson) E ALLONMEO SCHEOULE� AUTOS AUTOS BODILYINJURY�ParacciEant) $ HIREOAUTOS NON-0WNED PROPERTYDAMAGE AUTOS Peramtlent § E A X �M��u� OCCUR CUT0988N 3/4/2015 3/4/2016 EqCHOCCURRENGE $ 2000�000 E%CESSIJFB ClAIMS-MADE AGGREGATE S 2000000 DE� RETENTION$ E D wORKER3COMVEN5Al1oN W(,7pqggN 3/4/2015 3/4/2016 HNDEMPLOYptS'WBIl1TY ��N STATUTE ERH ANV PROPRIEfORIPFlRTNER/EXECUTIVE E.L.EACH ACCIDENT $ 5QQ QQQ OFFICERMIEMBEREXClU0ED9 � N/A �M°Ma�orymNx� E.L.DISEASE-EAEMPLOYE E SOO,OW H yB5,dBacnbe untler DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICV LIMIT $ SOO�000 OESCRIP1qN OF OPERATIONS/LOCAlqN51 VEHClES �FCORD 101,AtltlNonal RemaMs Schetluk,miy W aMacheE H more space b�aqul'etli Loc 1: 461 Station Ave.,Bass River,MA 02664-1649 loc 2: 790 Main 5[.,Chatham,MA 02633-1823 'Merrill5weet is excluded. CERTIFICATE HOLDER CANCELLATION SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TownofYarmouth 7NE EXPIRATION DATE THEREOF, NO710E YYILL BE DELNERED IN 1196 Rou[e 28 ACCORDANCE IMTH THE POLICV PROVISIONS. Soutfi Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE Q� �� ZVG OO 7988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014107) The ACORD name and logo are registered marks of ACORD