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Home My WebLink AboutApplication and WC co�� u- �`� � � ►� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT- 1 �� 15 � ;� r�,: `"'° * Please complete form and attach all necessaryp�dgcumen ' y � ecem` r 1 DEPT. ' Failure to do so will result in the return b�'your ap�licat�ori� � . �.�. E�TABLISHMENT NAME: r.•A TAX ID• LUCATION ADDRESS: � � , fy��- TEL.#: �b�1��-o � j 1VIAILING ADDRESS: E-MAIL ADDRESS: �..� � Co�e.�,.��C�tt�C��, ��w� OWNER NAME: CtJRPORATION NAME (IF APPLICABLE): MANAGER'S NAME: '"'�'rl�c�F*'�`�_ ,S TEL.#: �pk-"Yi'5�� 1VFAILING ADDRESS: � PbOL 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. �. � , - - , � . --- _ � - _ � '. '�.�� l� _ - - . _ _ -� , � 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.,,' N�\� �.}e.c.✓- 2. '.T_'�C\,A� 3.- �'.��:�-�� +5�0 4. �c... ,.. FbOD 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. 1.' 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � ' ____2��--_ _ ,� _ ___ ___ � _�—�_ -- �- - --- -- =- � ALLERGEN CERTIFICATIONS: Al�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.�'�! 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# LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT# _B&B $55 �CABIN $55 �!G-oo5 �MOTEL $110 � —0 _INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. � 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 $8U LICENS�REQUIRED FEE PERMIT# . LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SO 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 _ $ 385.00 *****PLEASE TURN(�1i,1�}SHk�UF� �HER 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 CO PENSATION 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 p or to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS . � �.LL�_ �,�:��a.._ _ __ LL.� �_.-_ __ ___ � _ � 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 colle�tion 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 in�pection 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. ix. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. __ . _ , - . - . _ ; �_• _ _ - FOOD SERV�CE ._ � � w �.. , � SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact t.�e 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 pnor 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 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 RETLTRN 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 APPROVED THE BOARD OF HEALTH PRIOR TO COM NC MENT. RENOVATIONS MAY RE UI SITE N. DATE: rZ O l� SIGNATURE:_� PRINT NAME& TITLE: �^�lG A��.T� Rev. 10/Ol/15 A��Q� CERTIFICATE OF LIABILITY INSURANGE °"�`�"�'°°","Y' P /17/201 THIS CERTiFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFER3 NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ' CERTIFICATE DOE& NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TME COVERAGE AFFORDED BY THE POUCIES � BEIOW. THIS CERTiFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(3), AUTMORIZEO REPRESENTATIVE OR PRODUCER,AND THE CERTIFICAT�HOLDER. IMPORTANT: If the certificate holder is an ADpITIONAL INSURED, the poiicy(fes) must be endorsed. If SUBROGATION 13 WAIVED, subject to � the terms and conditions of the policy,certain policies may require an endorsemenG A statement on this certificate does not confer righis to the � certificate holder in I(eu of such andorsement a. � PRoouceR N,nn�� Laura J Murphy MART INSURANCE AGENGY, INC. — ------- --- --- --- ;F�- ------- --- .-...___ __-- 243 MAIN STREET Pno"E . 508-759-7326 X207 508759-7366 � ac No. PO BOX 700 �oRe�s: ImurphyQhartinsuranceagency.com BUZZARDS BAY,MA 025320700 ` INSURER�S]AFfORDING COYERA6E __�____T__� NAIC 8 -----._.___._.__.__------- ------ - T--- u+suReRn: NORGUARD INS CO i i _..____..-- - -- -----------------.__ --------__----- —�---__--------....._._ ------____.__.�____--------------------------- --�.�------- �NSURED Colonial Acres Resort Association iNsuRER e: LLOYDS • �. —__._.___.-----�----------------------__.__.._ __. 114 Standish Way , West Yarmouth,MA 02673 INSURER C:_�_�_! � INSURER D: �� . � � INSURER E:�----- -.-----�------------ —�--- �.. MSURER F: COVERAGES CERTIFIGATE NtJME3ER: R�Vt$IQN NUNFB�R: THIS IS TO CERTIFY THAT THE POUCIES OF 1NSURANCE LISTED BEL01N HAVE BEEN ISSUED 70 THE INSURED'NAMED ABOVE'F(� �PERIOD � ' INDICATEO. NOIINITHSTANDING ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT OR OTHER bOCUMENT WITH RESPECT TO WHICH THIS � CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANGE AFFORDEO BY THE POLICIES DESGRIBED HEREIN IS SUBJECT TO AlL THE TERM5. , EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REOVCED BY PAID CLAIMS ' INSR i�----..�.------�----- � ---- ADDL�SUBNr---- ---'- --�-POUGY EFF �POLICY EXP -- ---------------------------- '�,... LTR TYt+F OF INSURANCE � T � � LIhHTS � ' 1 MI D/YVYY B (GENERALLIA8ILITY ; , OIIO�I2O�6 �qCHOCCURRENCE � S 1,000,000 �- : ; P XSZ47081R i 01 O1/2015, �A��'€6_��----.___._--_-------- I�COMMERCIAL GENERAL LiABIUTY � ; �_�RgMI ES(Eag��y(rencal.__��_. . .._ _... __ 50;000 i i CLA�MS•MADE ��i occuR � ��_ '�. � MEO EXP(AnY one person) s __, _ _ 5,000 � I __-.. _�. -�.�_� �,��0��0 ; � � � ! � � -� PERSONAI 8 AOV INJURV i 5 -- � ._---.___.�_. _.....---'-�-----`.--. � -. ; i '---'---------_,. . i i _-�_----�-'----'--' ; � :, I � ; `GENERALAGGREGATE� 5 ?,OOO,OOO -• -'--�----'-----------.-_ _ ; ----- �'----- � i PRpDUCT$•COMPrOP AGG t S 1,000,000 .GEN'L AGGREGATE LIMIT APPIIES PER � � � � � � � . � - � � --- � � �, i ; ----. . �._-�., . (' � PRO- r--i . �. . .' i i �._. _.r_S ... I, POLICY ' , � � ' i AUTOMOBILE UA8ILITY � � � i. . � . ' j i C MBMED SWGLE UMIT � i ( LOC f i �': L��f4Q�J__..._..�.__ __LL_------------ i ANV AUTO � , � i �BOD�LY INJURY(Per persan) � S i }.�__,_.^---- ALL OWNED SCHEDULE� �� - �'�; � � BODIL�fNJURY(Per eccitlenp S � .� AUTOS AUTOS t � 1 -�'-' - '--- NON-0WNEO � j '; PRpPERTY pAMAGE � s .. �---�-c d n ^^ HIREDAUTOS AUTOS I i i � 1 � r��-�-�«- ------�-s- --� UMBREI.LA LIAB OCCUR � � I I EACM OCCURRENCE S � i �EXCESS LIAB CLAIMS-MADE i I I I � AGGREGATE __T_ f S � _ � � I � —i s . - I DED RETENTION S ~! � � � WORKERSCOMPENSATION i ; COWC584953 08/01/2014�08/01/2015 i wCSTATU_•_ I �OTH� ' A �AND EMPIOYERS'UABIUTY Y!N i � ; ' - -�-��Y UMI1.�L-..�-- . ------.--- -- 4 !ANY PROPRIETORlPARTNER7EXECUTIVE � ' � ', �E.L_EACH ACCIDENT � S SOO,OOO , !OFiICER/MEMBER EXCLUDED9 N j N I A� � i � `� SOO,OOO ��Mandatory fnNH) �'� I ' I IrE'�.DISEASE-EA EMPLOvEE S _ �n ye�.aeaait»unaer � � I - _�v---T500,000 i DESCRIPTION. F OPERAT�ONS below i� � E.l.DISEASE�-POLICY UMIT .i 5 i _ . . . .. . .� _. . . .� ....� ,--. . - - . � . ... . • _ _.�. .., .:� _. . - �- . . . • _ . i.. . . . . . -.. i _ .. � I . - ' - i I i 1 � � I � ! OESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101,Atldltlonal RemaMs Sthedu�e,if more space Is requlrod) Operations as performed by Terms&Conditions in the policy CERTIFICATE HOIDER CANCELLATION � SHOULD ANY OF THE ABQVE DESCRIBED POLtCIES BE CANCELLEQ BEFORE � TOWN OF YARMOUTH THe EXPIRATION DATE THEREOF, NOTICE Wlll BE DELIVEREO IN 1146 MAIN STREET ACCORDANCE WITH THE POUCY PROViSION3. f S YARMOUTH,MA 02673 � AUTMORIZED REPRESENTATiVE j �•��.r+�� i s� r,�. •:A I �� _=a <_� ' �1988-2010 ACORD CORPORA710N. All rights reserved. ACORO 25(2010I05) The ACORD name and logo are registered marks of ACORD