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Home My WebLink AboutApplication and WC G3CC� �� • TOWN OF YARMOUTH BOARD OF HEALTH � � � � APPLICATION FOR LICENSE/P IT 2016R.( �A� � Q Z016 "� "'"' * Please complete form and attach all nece��- � ��b��e'�� ber 1 S 201 S. � i ' Failure to do so will result in the re��of�o�,a�i�icati a; ck PT. ESTABLISHMENT NAME: ��►�� S TAX ID: ��- ')�� LOCATION ADDRESS: L1 � �� Q�" � TEL.#: � �fS r7�'S �qGZ ; 1VIAILINGADDRESS: (.a 1 �� R� � GU�'Y�-� �'L� 11.r1� OZ.�`�� ; E-MAIL ADDRESS: �-1.�w11��0 � ��c� ; OWNER NAME: S�c2 � �1��- ' CORPORATION NAME (IF APPLICABLE): � f MANAGER'S NAME: � � � � �u- TEL.#: t F P� A U� �U t/ ; MAILING ADDRESS: �-t � �n � 2?S" (�1 k71'��t-�c�(�►C�'N 1�1-� d?.�,�~� `' : POOL CERTIFICATIONS: �Tb S�1i�1ti.�"� C'�`r•��i� �R-� OPE�N3Cr-�P�� 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. ; --�---1�-��.�,�'`�a�.P ,1--'�-.�L __ -2. - - _ _ _ i 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 file at your place of business. � 1. +� ��2 G�/�� 2. �C� `1�/'�t�� 3. ' � 4. k FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food i 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. L 2. , PERSON 1N 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. 4 1. 2. � i HEIMLICH CERTIFICATIONS: i 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. � F 1. 2. 3• 4. RESTAURANT SEATING: TOTAL# ; OFFICE USE ONLY � _ __--- - --- _ _ _----- � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQUIRED FEE P RMIT# _B&B $55 CABIN $55 1 MOTEL $110 � (o.�Q� INN $55 CAMP $55 =SWIMMING POOL$110ea.�� ; _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1 l0ea. j FOOD SERVICE: i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 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 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $I 10 � NAME CHANGE: $15 AMOUNT DUE _ $ 2Z.0•OQ i � � � ti *****PLEASE TURN OV��(�P�� R SIDE OF FORM***** � c — _ � 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 f 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 'i 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.Xarmouth.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. 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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. �.. _ . NOTICE:Permits run annually from Janua.ry 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2015. � LL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW A � EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QUIRE A SITE PLAN. DATE:�- �� IO�Lr� 1,6 SIGNATURE: � ' pRINT NAME &TITLE: � �'� °� h`�"` Rev.10/01/15 a Ciient#: 16866 2SUPER8MQ ACORD�, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMrYI� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONIY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER9 H�ISs � CERTIFICATE DOES NOT AFFIRMATIVELY 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(S),AUTHORIZED I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDI770NAL INSURED,the policy(ies)must be endorsed,lf SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this cer[�cate dces not confer rights to the cert�cate holder in lieu of such endorsement(s). PRODUCER ' Dowling&O'Neil Insurance Ag ` oNrAcr NAME: 9731yannough Rd,PO Box 1990 PHONE ac No �,�t:508 775-1620 a�,No; 5087781218 Hyannis, MA 02601 E�� I ADDRESS: 508 775-1620 INSURER(S)AFPORDING COVERAGE NAIC� INSURED — INSURERA:�-�O�/C�S Of LOf1tI0(1 Kishor Patel A/O Kiran K Patel A/O AUM 'iNsueeR a:A.I.M.Mutual Insurance Company COI'p.D/B/A I INSURER C: � 3 Algonquin Drive iNsuReR o: : Burlington,MA O�SO3 INSURERE: COVERAGES �NSURER F: CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED BOV,EABFOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RE4UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS CERTIFICATE MAY BE �SSUED 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 pA�D CLAIMS. INSR LTR TYPE OF INSUR,4NCE ��%$�B POLICY EFF pp�y� , INSR�NND POLICY NUMBER MlDD MNUDD j A GENERAL LIABILITY i LIM(TS ' ! j XSZ56337 HIZEIZO�J� OHIZGIZO'IGI EACHOCCURRENCE � XI COMMERCIAL GENER4L LIABILITY � . j I I$� OOO OOO i AMA�E Tp RENTED i CLAIMS-MApE �OCCUR � ;�REMISES(Ea occurrencel �S rJ�,O�� XI BUPD Ded:500 i � � �MED EXP(qny er�e pe�� i g5,000 i .: ; i IPERSONAL&ADVINJURY ;$'I,OOO�OOO GEN'L AGGREGATE LtMIT APPLIES PER: � i ! i GENERAL AGGREGATE I$2�000,000 ' POLICY r�ECT I�LOC � � I I PRODUCTS-COMP/OP qGG i$ ��AUTOMOBILE LIABILITY �, � j � ;$ ' � � ; 'COMBINED SINGLE LIMIT ' I ANY AUTO i : i Ea accident ;$ Ali OWNED ' I �AUTOS � SCHEDULED � I �BODILY INJURY(Per perspn) !g �AUTOS i �' i NON-0WNED � i � �BODILY INJURY(Per accident)j$ HIRED AUTOS _�qUTOS i i I . � � �fFe�aociden8 AMAGE '.$ ' ' I ! �UMBRELLq LIAB �'�-- ; . ;$ �I OCCUR � � � —�IXCESS LIq6 � � � � 'EACH OCCURRENCE i$ � , ., _ CLAIMS-MADEI i - � DED .' �RETENTION 5 : � 'AGGREGATE �$ B :WORKERS COMPENSAT1pN � I i ;AND EMPLOYERS'LIABILITY � � WMZ80080036422 /01/2016 04/OV201T X �T � Y I �� !ANY PROPRIETOR/PARTNER/EXECUTNE Y/N I j WC STATU- OTH- - �.OFFICER/MEMBER E X C L U D E D? �i N�A� i W M Z 8 0 0 8 0 0 3 6 4 2 2 4�O�/Z O�S O4/O�IZO�G'EL EACHACCIDENT I$rj00 000 � ;(Mandatory in NH) .. If yes,describe under I �E.L DISEASE-EA EMPLOYEEj$�J00 ODQ 'DESCRIP?10N OF OPERATIONS below ' I :E.L.DISEASE-PO�ICY LIMIT $rjOO,OOO � � i : � i r I i � � i DESCRIPTION OF OPERq'f10NS/LOCq77pNg�yEMCLES(Attach qCORD 101,q��onal Remarks Schedule,if more space is required) � Insurance coverage is limited to the terms,conditions,exciusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. � Insurance coverage is limited to the terms,conditions,exclusions,other � (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATI�N TOW11 Of YBRpOUth SHOULD ANY OF THE ABOVE DESCRtBED POLICIES BE CANCELLED BEFORE 1146 Rt 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN South Yarmouth,�/� Q266Q. ACCORDANCE WITH THE PO�ICY PROVISIONS. 0 AUTHORIZED REPRESENTATNE � ,�� ACORD 25(2010/OS) 1 of 2 The ACORD name and logo are registered marks of ACORDa_L�1�ACORD CORPORATION.All rights reserved. .#S 166774/M 166773 ; NS2 , � DESCRIPTIONS (Continued from Page 1) � limitations and endorsements. Nothing contained in the certificate of � insurance shall be deemed to have altered,waived,or e�ctended the �coverage provided by the policy provisions_ � � � , e f a I � i � � ( � � � + � . � i I i F 4{ `f t � � f i f � t i ! � ! � 1 � � � � � ; � i } 9 � ' i � � f i t � ' : : ; � 1 � � � SAGITTA 25.3(2010/05) 2 of 2 #S166774/M166773 � �