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Home My WebLink AboutApplication and WC' y � �cKS TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PE 2I ,�rr.., DtC , 6 :>015 �"� * Please complete form and attach all necess�ry�t5� ecem er IS 2015. Failure to do so will result in the return of yqur a�plicattan,pac et. DEPT. ESTABLISHMENT NAME: TAX ID: �- LOCATION ADDRESS:�C' n. in S-�a o-� T$L.#: Spif- 771– 50�1� MAILING ADDRESS: E-MAIL ADDRESS: e � OWNER NAME: 1av 2am �s CORPORATION NAME (IF A LICABLE): MANAGER'S NAME:� ,r�� h-I�a.(pYl 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. L _ _ 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 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 Aealth Department will not use past years' records. You must provide new copies and maintain a Tile at your establishment. 1. `1'�oL �1Pa.io,n 2. "�ia,rn� r, c�u,rrb PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �C.. 1�2�G,�� 2. ALLERGEN CERTIFICATIONS: All food service establishments arerequired 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 Tile at your establishment. i. �m��t A N v l� 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# _ _— __ --- ---__ _ _ [1EFrrF. rr� rnvi..X—_ __ � LODGING: �� LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT k B&B $55 CABIN $55 MOTEL $ll0 � INN $55 CAMP $55 SWIMMINGPOOL$ItOea LODGE $55 TRAILERPARK $105 WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 �'� LCOMMON VIC. $60 �� =RES�ID.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 NAME CHANGE: $15 AMOUNT DUE _ $ 26�_04 •****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 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 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 thir[y(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 ar 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 Deparhnent to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth Health Departinent 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.yarmouth.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 tn 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, MOTEL O POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND PPROVED, E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY U A SIT A \ I DATE: \� t�� SIGNATURE: '� PRINT NAME& TITLE: �JCIYL l t Rev. 10/01/IS Client#:42037 2REDFA DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 70/28/2075 THIS CERTIFICATE IS IS3UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT3 UPON THE CERTIFICATE HOLDER.THI3 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endoraed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(a). PRODUCER NAME: Dowling&O'Neil Insurance Ag a�"o E,�:508 775-1620 �uc,No: 5087781218 973 lyannough Rd,PO Box 1990 E-MAIL Hyannis,MA 02601 ADDRESS: rJO$775-�GZO INSURER(8)APFORDING COVERAGE NAIC A �r,suaeRn:Guard Insurance Group INSURED ,Nsu,x�R B:The Hartford Red Face Jack's,Inc DBA Red Face Jacks C/0 The Yarmouth House Restaurant INSURER C: 335 Main Street INSURER D: West Yarmouth, MA 02673 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THiS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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. LTR TYPE OF INSURANCE NSR YWD POLICY NUMBER MMroD/YYEYYI MM/ODY�P LIMITS A GENERAL LIABILtTY REBP612595 8h 2/2015 08/12/201 EACH OCCURRENCE s 1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES EaE�rrence $5O OOO CLAIMS•MADE a OCCUR MED EXP(Any one peraon) $rJ,�� PERSONAL&ADV INJURY $��OOO OOO CaENERALAGGREGATE $Z�OOO,OOO GEN'L AGGREGATE UMIT APPLIES PER: � PRODUCTS-COMP/OP AGG $Z�OOO�OOO POLICY PRa LOC $ A AUTOMOBILE LIABILRY REBP612595 8/12/2015 OS/12/201 EO aBIN�ED SINGLE LIMIT 7,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Peraccident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE � AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 08WECCF1832 5N 6/2015 05/16/201 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORlPARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $SOO OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH► E.L.DISEASE-EA EMPLOYEE $rJOO,OOO DESCRIPT�ION OF OPERATIONS below E.L.DISEASE-POLICY IIMIT $rJOO�OOO A Liquor Liab REBP612595 8/12l2015 08/12/201 $1,000,000 per occ �2,000,000 aggregate DESCRIPTION OF OPERA7ION3/LOCATIONS/VEHICLE8(Attach ACORD 701,Atlditlonal Remarka 8ehedule,H more apace Is requlred) Evangelia Zambelis is excluded from the workers compensation policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,walved,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE�LED BEFORE THE EXPIRATION DATE TFIEREOF, NOTICE WILL BE DELIVERED IN 'I'I46 ROUt@ ZH ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-4492 AUTHORIZED REPRESENTATNE -�..,,� �.�---�--�- �1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S159950/M159948 LS1