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Home My WebLink AboutApplication and WC- ; � A�PRfzr-iq 5 TOWN OF YARMOUTH BOARD OF HEALTH ��b�p �� APPLICATION FOR LICENSE/PE�N�fT- 14S�2 ; * Please complete form and attach a11 necessary ocn e�y Dece b�� '20�Z Q 15 Failure to do so will result in the return o�your�ppkeati�an pa et. HEALTH DEPT. ESTABLISHMENT NAME: TAX ID: LOCATIONADDRESS: 11 Ll-1,P1 TEL.#: �7'71-7�7�7 MAILING ADDRESS: E-MAIL ADDRESS�'��„�r yr�� n�d� �rm� OWNERNAME: �VQ 2� h�1� 5 CORPORATION NAME I�F APPLICABLE): YY� � � , MANAGER'S NAME: � �2Y\�axn�n �r r � TEL.#: 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 --- - -__ . _ 2: - - - - -- 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 61e at your place of business. 1. 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 Health DepaMment will not use past years'records. You must provide new copies and maintain a file at your establishment. i.�cr.m�n s�,. � z. �(.i.� ►arL� C-�us�n�au PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 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. � .�.l.t.Y✓6 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. t�►� �,�,✓vv a.2�en is� ,5c hio�c� 3. 4. RESTAURANT SEATING: TOTAL # ---- - -- --�F��EIJS_F._Q1YL�_---- -- _ _ �vuciNc: 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$110ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT H 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 �Co �COMMON VIC. $60 �3�j _��D.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 $I10 NnME cxnrvcE: S�s AMOUNT DUE _ $ 260.o0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ,�-ic ADMINISTRATION 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 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 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 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 Yarmouth must notify the Yazmouth 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.yarmouthma.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 Board 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, M TE OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPR Y THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS M E PLAN. / DATE: �� SIGNATURE:✓� � PRINTNAME & TIT . CL_YICP`� 4iN1 o��s �(eStde� Rev. 10/01/15 . . Client#:22800 2DIPARMA ACORD.w CERTIFICATE OF LIABILITY INSURANCE OAtE(MMIOD/YYY1� 10/28/2015 THIS CERTIPICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF�NSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:N the certficate holder is an ADDITIONAL INSURED,the poliey(ies)must be endorsed.If SUBROGATION IS WAIVED,subjeet to Me terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confe�riAhts to She certificate holder in lieu of such endorsemenys). PRODUGER ' �E: Dowling 8 O'Neillnsurance Ag PNONE 5p8 775•1620 5087781218 ac r+ �n: ac.No: 973 lyannough Rd,PO Boz 1990 E+�ua ApDRESS: Hyannis,MA 02601 INSURER�S)AFFORDINGCOVERRGE NAICp 508 775-1620 iNsuRERA:Guard Insurance Group INSUMED IN8URER B: Calamari, Inc DBA DiParma Italian Table INSURER C: NO Tasty Tidbits Realty Trust 775 Main Street �nsurseR o: INSURER E: West Yarmouth, MA 02673 INSURER F: COVERAGES CER7IFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED. NOTWITHSTANDING ANV RE�UIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 6Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CUIIMS. INSR rypE OF INSURANCE AODLSUBR VOLICY EFF POLIGY E%P uMITB LTR INSR NND VOLICYNUMBER MMIDD MMIDD A GENERALW&LffY CABP617732 6/15/201506N5/207 EpAqC�Hp�OECCURRENCE $'IOOOOOO X COMMERCIALGENERALLIABILITV PREMISES EaEONm.�urrence $rJOOOO CLAIMS-MADE �OCCUR MEDE%P(Arryoriepersan) $S�OOO PERSONAL 8 ADV INJURV $'I OOO OOO GENERALAGGREGATE $Z�OOO�OOO GEN'LAGGREGATELIMITAP�LIESPER: PROOUCTS-CAMP/OPAGG $��OOO�OOO POLICY PR� LOC $ AUTOMOBILE LIN&LRY COMBINEO SINGLE LIMIT Ea acritlent ANVAUTO 6WILVINJURY(Pe�pemn) $ ALLOWNED SCHEDULED BODILVINJURY(Pe�acdEenQ $ AUTOS AUTOS NONAWNED PROPERNOAMAGE $ HIREDAUTOS AUTOS Peracaden� $ UMBRELULlAB pCCUR EACHOCCURRENCE $ ��B CLAIMSMADE AGGREGATE § � DED RETENTION$ $ A WORKERSCOMPEN8AT10N CAWC698973 6/Ot/2015 O6/01/201 X '"csrnru- orw RND EMPLOYERS'lAl1BILRY OfFICEWMEMBEREXCLU�D?ECUTIVE� N/A E.L.EACHACCIUENT $�JOOOOO (Mandatory M NX) E.L.DISEASE�EA EMPLOYEE $SOO OOO DESC P�TI„ONOFOPERATIONSbelow E.LDISEASE-POLICYLIMIT $SOO�OOO A Liquor Liab CABP617132 6N5/2015 06N5/201 E1,000,000 per occ E2,000,000 aggregate OESCRIPiION OF OPERAl10N8/LOCATIONS/VEMICLES ulpae�NCOftO 707,FGOlibnel Rema�ks 9e�etluk,H more apaee Is requl�aC) Insurance coverage is limited to the tertns,conditions,exclusions,other Ilmitatlons and endorsements. Nothing contained in the certificate of fnsurance shall be deemed to have akered,waived,or extended the coverage provided by the policy provisions.Members are included under the workere compensatlon poliq. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHWLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TXE EXPIRATION DATE TXEREOF, N0710E WILL BE DELNEREO IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 SouthYarmouth, MA 02664 AUTHOPoZEOREPRESENTATIVE '�+'7�—� �� 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) � p{p The ACORD name and logo are regisMred marks of ACORD #S159952/M759957 LS7