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Home My WebLink AboutApplication and WC . T�3��}�:� �.r � � - - ► TOWN OF YARMOUTH BOARD OF HEALT -� e��:��, � � APPLICATION FOR LICENSE/P � , , � r1' �`�; �E� �+ 4 ZO15 "'"' * Please complete form and attach all necessary�d�cutr� ss�� y� e� r 1 DEPT. Failure to do so will result in the return o�our�pp ication pack . ESTABLISHMENT NAME: fl1 .e T ID• LOCATION ADDRESS: a.`a S� �a8 W 6� fI o��,� TEL.#• d -'��uf'-vr/,Svr` 1VIAILING ADDRESS: � E-MAILADDRESS: � �P� � -lv '�?-�� OWNER NAME: ��/��cr� p se/�sL /l o.��n:ufi 7",P,+�S CORPORATION NAME (IF APPLICABLE): M!ANAGER'S NAME: � ,�a✓.' S TEL.#: 'a .. S v"i,�,�- MAILING ADDRESS:�� /yh�'� S� � ZU ow /rD'r�1 �L�� PbOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. T`Iease list the designated Pool Operator(s) and attach a copy of the certification to this form. �9 �j . -- _�. _'�"C�/m j/�'tt<� - - _ _ ` - -�-- - -__ � - — ---- Pool operators must list a minimum of two employees currently certified in st�> a.rd First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on pre� `ses at all times. Please list the employees below and attach copies of their certifications to this form. The He ' �Deparhnent will not use past years' records. You must provide new copies and maintain a file at youi ,�lace of business. 1.,, L�2��: ;� � CA� -��f� . 2. ��1J �d ��,` -� S 3.' G �a�►% s" 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 Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. L �� 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: �lI 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.' /r/� 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# ----- _ _ v r �,r. � vivi,� � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�yRMITo#39 B&B $55 CABIN $55 I MOTEL � $110 � _INN $55 CAMP $55 �SWIMMING POOL$110ea��o"7/ _LODGE $55 —TRAILER PARK $105 �WHIRLPOOL $I l0ea. 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 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSfi 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: $is AMOUNT DUE _ $ ?►-�6+�s0 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �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 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 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.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. 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 Boazd 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 REQUT A SITE P N DATE: ��✓� SIGNATURE: "'�� ' �--�' • PRiNT NAME & TITLE: �6�" �Z✓� s ' �an� �'" Rev. 10/01/15 Client#:2$398 YARMORESOR onTe(Mrwovrvrv) ACORDTM CERTIFICATE �F LIABILITY INSURANCE �tiov2o�s Ti11S CERTIFICATE IS 13SUEQ AS A MATTER OF INFORMATION ONLY AND CONFERS NO R1t3HT8 UPQN THE CERTIFICATE HOLDER.THIS CERTIFtCATE DOES NOT AFFIRMATNE�Y OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE APFORDED BY THE POLICIES BELOW.THIS CERTtFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTr2ACT BETWEEN TH�ISSUING INSURER(S),AUTHORIZED REPRESENTAtIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certiflcate hofder is an ADDITWNAL INSURED,the policy(iss)must be endorsed.ff SUBROGATION IS WAIVED,subJect to ths terms and conditions of the policy,certain polici�a may require an endarsement.A statsment on thts certificate does not Confer rfghts to the certlficate holder in Ileu of such endarsemerrt(s). PRODUCER Smith insurance,lnc. � .860739-33Y2 N,;860-739-9494 15 Liberty Way E�L Niantic,CT 06357 �Ng��tER(g)pFFatWNG COVERAGE r�uuc# 860 739�322 n�suR�A:Hartford Casualiy Company INSURED INSURER 6- Yarmouth Resort Condominium Trust Inc �NSURER C: 343 Route 28 iNBURER D: West Yarmouth,AAA 02673 tNSURER E: INSURER F• COVERAGES CERTIFICATE NUMBER: REVISION NUMBfR: 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 COND1710N OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,. . EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LIMfTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L� TYPE�INSURANCE B POLICY NUMBER POLICY Y EXP � 6ENERAL UABILITY EACH OCCUWiENCE S COMMERCWL OENERAL LIABIIITY PREMISES Ea�o�caarenoe S CLAIMS-MADE �OCCUR MED IXP(My aie per�n) $ PERSONAL 8 ADV INJURY $ GENERAL.AGGREGATE $ GEN'L qCiGREGATE LIMIT APPLIES PER: PRO�UCTS-COMP/OP AGG $ POLICY PRO- �� $ AUTOMOBILE IJABILITY (�AAB�SINGLE UMIT ANY AUTO �ILY tNJURY(Per person) $ ALL OWNED SCHEDULEO BODILY INJURY(Per acxtident) $ NiRED AUTOS ��ED PPROPERTY DAMAC,E $ $ UMBRELLA LIAB pCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S \ f A "��"s^`n� 02WEGW7666 2/211201512/21/201 x ��A�' oT"- AND EMPLOYERS'LIABIIRY ANY PROPRIETORlPARTNERlEXECUTIVE Y�N E.�.EACH ACCIDENT a100 000 OFFICER/MEMBER EXCLUDED't a N(A (Manda�ry in NH) E.L.DISEASE-EA EMPLOYEE $�� Ifyes desaibe ur�r DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO OOO DESCWPTION QF OPERA710NS i LOCATIONS/VEHICLES(Attach ACORD 107.Additlonal Ramarlcs SdpMde,if mae spaes ic n4ui►edi CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE YYN.L BE DHLIVERED IN 1746 Route 28 ACCORDANCE WITH THE POLICY PROVISIdN3. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I �� • �1988 2070 ACORD CORPORATION.Ail�ights reserved. ACORD 25(2010/05} 1 of 1 The ACORD name and logo are registered roarks of ACORD #5895391M89538 �M