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Home My WebLink AboutApplication and WC : ,. G3��i�u"u�D � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICEN� , f T�-�0��='� �ti r �� O�b _- �., " * Please complete form and attach a11 nec � °� � . c f:b ' S_pT ' Failure to do so will result in the r��rn "� lt�t on �' ESTABLISHMENT NAME: � TAX ID: � LOCATION ADDRESS: �al�-1 N1C•a`,n S-ke�� ee1- 4Arrno TEL.#:�`b�'1S-�153� MAILING ADDRESS: I�-.�' i (t'-�vv► ��ee�- vC>eKcmlt, M� c�'t�'7'7 l E-MAIL ADDRESS: 1, OWNER NAME: ti ' CORPORATION NAME (I APPLICABLE): e_�y�y l��r�. SnL "� 1`� - ' MANAGER'S NAME: �o�.►•��n Ll�� TEL.#: (o�l��3y 9 MAILING ADDRESS:=_��,vu s�- S�ee tLen�..l� E"�G� 02�"7/ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated P4o1 Operator(s) and attach a copy of the certification to this form. 1. 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 file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: A�1 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) 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 Sanitaty 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.' 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�le at your place of business. ; 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: 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 TRAILER PARK $105 WHIRLPOOL $I l0ea. FOOD SERVICE: LICENSE REQUIRED FEE E�2M ,�j LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 L(o��`[ _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 �O _WHOLESALE $80 —RESID.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: $1 s AMOUNT DUE _ $ f 8 5�O D *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** [ � 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 l , TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be j limited to the temporary and short term occupancy,ordinarily and customarily associa�ted 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. ' i 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 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: ' 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 OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY IRE A SITE PLAN. DATE: 3'(2 "(S SIGNATU - (� PRINT NAME&TITLE: Rev. 10/01115 E M ,4coR � CERTIFICATE OF LIABILITY INSURANCE ��'�3 2 '16 THS CERTIFICATE IS ISSUED AS A AAATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER. THS CER7IFICATE DOES NOT AFFIRMA7IVELY OR NEGATIVELY AMEND, EXTEND OR AL7ER THE COVERAGE AFFORDED BY THE POLJCIES BELOW. THIS CERTIFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOPoZED REPRESENTAl1VE OR PRODUCER,AND THE CERTIFlCATE HOLDER. IMPORTANT: If the certificate hdder is an ADDITIONAL INSURED,U�e polic�es) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditioru ofthe policy,certain policies may require an endorsement. A statemerrt on this certificate dces not confer rights to the certificate holder in lieu of such endorsement(s. PROIXICER CONTACT NANE: Robert M. Zagami Insurance P�NE 781 337-4033 FPiX N ; (781) 33�-aio3 Agency no�Ess: bza ami@rmzinsurance.com 555 Bridge Street iNsu� S AFFORDING COVERAGE NAIC# Weymouth, MA 02191 ir�suR�n:Travelers INSURm INSURER B: PETROLIBA INC ir�uR�c: dba Heavenly Restaurant �µ�RERD: 159 Elm Street INSURER E: Seekonk, MA 02771 �NSURERF: 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. NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Wff H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOFtDED BY TFE 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 A��SUBR P��ER PMI D/YE� NM�d�YY�YY LIMTS GENERALLU161LITY EACHOCCURRENCE $ COMMERCIALGENER4LLIABILITY DAMAGETORENTED $ CLAIMS�ADE �OOCUR MED EXP(Arry one persm) $ PERSOfy4L&ADVINJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-OOMP/OPAGG $ POLICY PRa LOC $ fWTOMOBILELIABIl1TY CON�IN�D�SINGLELIMIT $ ANYAUTO BODILY INJURY(Per person) $ ALLOWPED SCHEDULED BODILYINJURY(Peraccident) $ AUTOS AUTOS NON-OWNED PROPERfYDAMAGE $ HIREDAUTOS _AUTOS erawident $ �� OCCUR EACH OCCURRENCE $ IXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ A w�K�rssconnaeNsanon� UB9G091610 3/s/16 3/e/i� WCSTATU- OTH- awo ennP�oreRs��weiuTv ANYPROPRIETOR/PARTNER/EXECUTNE Y�N N�A E.L.EACHACqOEM $ J�OO OOO OFFICERIMEMBER EXCLl.OED? � � (AAandabryinNH) E.L.DISEASE-EAEMPLOYEE $ SOO OOO DESCRPTIONUOFOPERATIONSbelow E.L.DISEASE-POLICYLIMIT J�OO OOO OESCRIPTION OF OPERA710NS/LOCATIONS/VEHICIFS (Atqch ACORD 107,Additional Re�rerks Schedule,if more apace k req�f red) Heavenly Restaurant - Located at 194 Main Street, West Yarmouth, MA 02673 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POI.ICIES BE CANCELLED BEFORE TI� EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health 1146 Route ZS AU7HORI�DREPI�SENTAi1VE South Yarmouth, MA 02664-4492 Robert M. Za ami O 1988-2010 ACORD CORPORATION. All rights reserv�ed. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: