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Home My WebLink AboutApplication and WC � : ��l"�D6 : � ► TOWN OF YARMOUTH BOARD OF HEALTH �,;��.; � : ��15 � � APPLICATION FOR LICENSE/PERMIT -201G . "�T' {",M. ``" * Please complete form and attach all necessary dc��t�i�nts.b�Dece be�L2A��EPT. ' Failure to do so will result in the return of�dur a� ' ti n ac e t, E�TABLISHMENT NAME: � T ID• LOCATION ADDRESS: �,� � � TEL.#: �I MAILING ADDRESS: E-MAIL ADDRESS: �.,��u C� 0\�! `1 co-� bw��v�+�n S . CD�1 ' OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: �'t1,lClfl��t��S TEL.#: So� ;��X-�'r1�1YI 1VTAILING ADDRESS: ' PbOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pbol Operator(s)and attach a copy of the certification to this fortn. - — _ .. � — ---- _�_- -- _ � __.._ — -— t,`�n �,.a.rz� � �. - _ 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. Th,�C��'\ � �iTS 2. �w/l�Ul. �✓S�O�-. , 3. . ��n��e. 4. ,A(Lst� c•�--.• ' FOOD PROTECTION MANAGERS - CERTIFICATIONS: i 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 Department will not use past years'records. ; You must provide new copies and maintain a file at your establishment. � 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) an site during hours of operation. 1„-r,�-_._��_._ _ 2. � � - 1�LLERGEN 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 k provide new copies and maintain a file at your establishment. ' � 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 tl�e premises at all times. Please list your employees trained in anti-chokmg procedures below and i attach copies of employee certifications to this form. The Health Department will not use past years' records. j You must provide new copies and maintain a file at your place of business. ; ; 1. 2, 3. 4, RESTAURANT SEATING: TOTAL# I _ _�FFI�� I�SE E}AT�:Y __ _ _ --_ --- — LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 �MOTEL $110 —OL� —I� $55 CAMP $55 �SWIMMING POOL$I l0ea,�� _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. Z FOOD SERVICE: ; 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 LICENSB 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. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ 33�• OO � *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � � . � I i i 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 � I 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 k 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 I 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 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 j � 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;varmouth.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: � t Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � __ _-- -- ---e - �--- - � �_,,, - _- � ; ---- � r 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., PATNTING, NEW ; EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; DATE: SIGNATURE: PRiNT NAME & TITLE: Rev. 10/01/15 � - i �� DATE(MMIDO/VYYY) �'� A�o,Rp CERTIFICATE OF LIABILITY INSURANCE s�,��zo, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CER7IFICATE DOES NOT AFFIRMATIVELY OR NEGATfVELY AhiEND, EXTEND OR AITER THE COVERAGE AFFORDED BY TME POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CQNSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER. IMPORTANT: If the certificate holder is an ADDITiONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,ceRain poiicfes may require an endorsement A statement on this certificate does not confer rights to the certificate holder in Ifeu of such endorsement(s). PRODUCER _N�E• Laura J Murphy HART INSURANCE AGENCY, INC. ----------------------- ----- -- ---__- --------._.._ 243 MAIN STREET PH�E � (508)759-7326 j�� N,�. (508)759-7366 PO BOX 700 �oR�ess:.�murphy@hartinsuranceagency.com ___ --- BUZZARDS BAY,MA 025320700 INSURER S AFFORDING COVERACiE__ _ __ _ _____I NAIC M ._--- .___._.-�----_...--'-----{-� --- . . - - - ---- - - -t----`-----.. wsureeRn: Scottsdale InsuranCe Company � - - - ------------ __._ _ _--------- -____._ -------------------- --- __ ----__ _- --- _ _ - - INSURED Pier 7 Condominium Trust � iNsuRER e: Liberty Insurance Underwriters . 711 Route 28 __�__---- __ _._ ,-- --. ..-- - -- ---* _ _ South Yarmouth,MA O�6F)4 _!NSURER C: — - .— _.__ .�r — __._. _. - --- __J - . --- � INSURER D: __._. � � � INSURER E_ � ---- ...------` - ------- --__..._----- _.__. ._.___-._. ___.--- ----__._.-- ---..._. � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS Tp CERTIFY TNAT THE POUCIES ElF INSURANCE LISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PpUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER pOCUMENT WITN RESPECT TO WHICH THIS - CERTIFICATE MAY BE ISSUEQ QR MAY PERTAIN. THE INSURANCE AFFORpED BY TME POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BM PAIp CLAIMS. .__._ _.__ ____ ,_ __--___._--. ---__ ___.-- ------ -...___ - r---._.. INSR.' ..-.__.��...---TYPE OF IMSURANCE� ..��..._�.... jADDL�SUBR'._... .....�..POUCY NUMBER �� MM/DD/YVYV ' MMlDD YYV`/ �� LIMITS .. LTR ' B I GENERALLIABILITY '�, � .' (�.P52��989 I 01/O1/ZO15�; O1lO1/ZO16�� Eq�HOCCURRENCE ', S _ , - 1,000.000 �.. � � ��DAMAGE T�RENT�p� �� a �� i�COMMERCIAI GENERAL LIABIUTY I ; PR�M�$E�(��QGSurcQ�e�_ , _. __ O OOO �� , � , 5 �. � CLAIMS-MADE i� OCCUR ��'�, '�, ', �I MED EXP(Any one person) 5 _ 5 OOO_ � � � �� i i � i �' �. PERSONAL&ApV INJURY� 'S �,OOO,OOO :. ' �----- ----�-_._.. _ ._.. _ ..__ , ,� : .._.--�-------- -. i.... __... . __. �_. . ; ' i GENERALAGGREGn7E �S Z,OOO,OOO �._ .i _.....--------... ....._.---- ...._.. __ . �: --- - ---�-- � -�. GEN'L AGGREGATE LIMIT APPUES PER: j j �I i ��j � PRODUCTS•COMPlOP AGG �. S �.00O,OOO ��. -----._...--.—---- ----. ,-__; POUCY - i --- , , � � � --— -- �� PRO• I I, LOC i i ( I S , nUTOnnOB��E une�Lm I ! ; i COMBiN D SINGLE LtMtT ; i-(�_��L__. _.. ��`---- - _._. . BODIIY INJURY(Per person) I f . � I i ; , '-— � --- �-- - -- --__. �ANY hUTO . . r--- —r- � ��-�ALL ONRJED � SCHEDUIED � :, '. BQDILY INJURY(Per axidenp 5 --�FUTOS i AUTOS � II i f --- - -_- -- --. � NON-0WNED� '� � ' � PROPERTY DAMAGE � j ;HIREDAUTOS AUTOS ' � i � i-�-p��e�j�---- � f ._..� , --'---�---, . .-- ---� _._.. i i i5 ��; ; UMBRELLA LIAB OCCUR ' . ' � I I EACN OCCURRENCE ', S �,...._._. i , .� I � �_---�--------'-------- -^----- - ----.__----`- � EJ(CE53 LIAB C�qIMS-MADE i i % � ! AGGREGA7E b ---- ---.___...- --'------ -------- ....— '---- ----- � � � �._._._ _ DED RETEN710N 5 i � � �s � �: WORKERSCOMPENSATION � i I ! .��LAIMITS ' ��E�. .- . . . . - --.- IAND EMPLOYERS'LIABI4ITY I , �.. ��. . .'- 1 — . . .---.-. --_- . � Y!N i � ;ANY PROPRIETOR/PARTNERIEXECUTIVE i N�A i � j � E.L.EAGH ACCIDENT - 5 i OFFICER/MEMBER EXCLUDED� ' ' � � � � Y � ' i (Mandatory In NH) ; : �. I I., I_E l_DISEASE-EA EMPLOYEE- S ' il yes.0escribeuntler '. �. ., . .. .. _------ ------ -_+---_. _._..------------ I DESCRIPTION OF OPERA7IONS below � � � ' E L O�SEASE�POIICY LIMIT ' S ; I ! � i � i i DESCRIPTION pF OPERATION81 LOCA7tONS I VEMICLES (Atlach ACORD 101,Atldiqonal Remarks Schsdula,M moro spacs is mquired) � Operations as performed by Terms 8�Conditions in the poiicy ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THfREOF, NOTICE WILL BE DELIVERED IN 11A6 Main Street ACCORDANCE WITH THE POIICY PROVISIONS. South Yarmouth,Ma. 02664 AUTHORIZED REPRESENTATVE ��.. �"�f� �1988-2010 ACORD CORPQRATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �