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Home My WebLink AboutApplication and WCS r, �- � TOWN OF YARMOUTH BOARD OF HEALTH ' �� " APPLICATION FOR LICENSE/P R�II�O l�b�E�� pE(; , B >015 '"'' * Please complete form and attach all necess a r}�docume s by Dec m r 1 S 2015. Fai lure to do so will result in the return pf;you�a��ic�on p t. DEPT. ESTABLISHMENT NAME: T ID: � - LOCATION ADDRESS:��S �-+'l `7� p o "*" TEL.#: MAILING ADDRESS: E-MAILADDRESS: ��Gtf(�th�'tY��nAS�2.YpS ��Y/'av� t.C+��.0 I c �� OWNER NAME: �— � �� CORPORATION NAME (IF APP CABLE)• nw v��i S �n � Q�i SeS MANAGER'S NAME: I i TEL.#: • 7 7 - J 5�� MAILING ADDRESS: � S YYIC� ��l d o t. 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. � _ 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. L 2. 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.`�']\ l � ric 1Z 2. �� t. �C�fYI� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1.----��\ lGt �5 __ 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. C�{ ,Y 1`''1 t7 'f�-�--�� `� 2. l�.t,��-/ � ) �1'`(.�Cf� 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# — -- -------- _ _{�FFirc Ltg� n;y�?�_ —_ _ _ —_ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUfRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$I l0ea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# UCENSE REQUIRED FEE PERMIT# 0-100SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>I00 SEATS $200 .�6�8 1 COMMON VIC. $60 � =RES�IDEKITCHEN $80 RETAILSERVICE: LICENSE REQUIRED FEE PERMIT# LICF.NSF.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 $I(0 NnMect�nn�cE: $�s AMOUNTDUE _ $ `��h *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,tne Town of Yarmouth is now requiced to hold issuance ot tcn�wal 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 INSUIiANCE 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 ofthe 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 thirry(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 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 DeparUnent 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.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 to the Health Department. Failwe 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, MOT L OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVE HE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE IRE A S AN. DATE: ��\�11� SIGNATURE: PRINT NAME & TITLE: [��/j�p{�.I�A �iM��tS Rev. 10/01/IS Client#: 20816 2YARMHO ACORD.M CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDOIYYYY) 10128/2015 TXIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY TME POLICIES � BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIPICATE HOLDER. --__ ._____ _ IMPOR7ANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject ro the terms and conditions of the policy,eertain policies may require an endorsement.A sWlement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s�. PROOUCER . NANEp T Dowling 8 O'Neil Insurance Ag PpkNNo Ez�:SOB 775-'IBZO ac,no: �87781218 973 lyannough Rd, PO Box 1990 E-MAIL nno s: Hyannis,MA 02601 INSURER�S)AFFORDINGCOVERAGE NI.IC# 508 775-1620 iNsuRER A:Tudor Insurance Company � INSVqFO iNsuRene:Guard Insurance Group Kounadis Enterprises,Inc. D/B/A INSURER C: Yarmouth House Restaurant INSURER D: 335 Main St�eet ixsueea e: - West Yarmouth, MA 02673 INSURER F: � COVERAGES CERTIfICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSl1RED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANV REQUIREMENT, TERM OR CONDITIONOF ANV CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIfICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MEREIN IS SUBJECT 70 ALL 7HE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. �qR TYPEOFINSURqNCE ADRLSUpR pO�ILVNUMBER MMNDIT9EYl1 MMIDD/YYYYY LIMITS A GENEflALL1A81UTY PGP0754606 4/01/2015 04101/201 EpACH�OCCiUftRENCE S� OOOOOO X COMMERCIAL GENERAL LIABILITY PREMISES EaEo�ccurtenw 8700 OOO CLAIMS-MADF a OCCUR MED EXP(Any one petsan) s5 000 PERSONAL 8 AOV INJURY $� OOO OOO GENERNLAGGREGATE ST�OOO�OOO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $Z�OOO�OOO POLICY PRa LOC $ AUTOMOBILE LIN&LITY COMBINED SINGLE LIMIT Ea e¢iEent PNV AUTO 9001LV INJURV(Per person) $ � AILOWNED SCHEOULED BODILYINJURY(Perauident) $ AUTOS NON-OWNED PROPERTV a1MAGE HIRE�AUT0.S AUTOS Peracntlenl $ a UMBftELLA WB ppCUR EACH OCCURRENCE $ E%CESSLWB CLAIMS�MAOE AGGREGATE $ DE� NETENTION$ � S B WORKER9GOMPENSATION KOWCGS�L7B2 S/O�IYO'IS OS/O'I/YO� X wCSTATU- OTH- ANO EMVLOYERS'LUBILITY $Y�� ANY PftOPRIETOR/PARTNER/EXECUTIVE� EL EACH qGGIpENT $SUU UUO OFFICERIMEMBERE%CLUDED'! N N/A �MsntlatorylnNN) E.LDISEASE-EAEMPLOYEE $SOO�OOO tlyas,tleacn0e untler DESCRIPTION OF OPERATIONS bebw E.L.DISEASE POLICV LIMIT $SOO�OOO A Liquor Liab PGP0754606 07/2015 04l01/201 E1,000,000 per occ 52,000,000 aggregate DEBCRIPTION OF OPERATIONS/LOCNTIONS/VEHICLES(Attach ACORD 101.AtlOkbnal Remarka Sc�W ule,If mom apace Is repulntl) Insurance coverage is limited to the terms,conditions,exclusions,other � Ilmltations and endorsements. Nothing contained in the certiflcate of Insurance shall be deemed to have altered,waived,or extended the coverage provided by the pollcy provisions. � � CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLE�BEFORE THE E%PIRATION DATE TXEREOF, NOTICE WILL BE DELIVERED IN 1146 RO4fe 28 ACCORDANCE WI7H 7NE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTMORIZED REPRESEf1TATIVE �✓/..,,.�. ��,� �1988-2010 ACORD CORPORATION.AII rights reservad. ACORD 25(20�OI05) 1 of 1 The ACORD name and logo are registered marks ot ACORD #57599471M159945 LS7