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Home My WebLink AboutApplication and WC . . Y `�a�-�� TOWN OF YARMOUTH BOARD OF HEALTH � �� `� ,��-� .�� APPLICATION FOR LICENSE/PE�7�� a� �`}' ��a�' ��'� ��"'s�'�.`""'�0 r r �� * Please complete form and attach a11 necessary do�`�tn� c� ,x AP{� �?� �� ri� I S 2014. Failure to do so will result in the return of�ur ` cation pac t. HEALT�I �EPT. ESTABLISHMENT NAME:�a�w►�.�� ym��1, 13.t�.1,o�I +�� ;�c. TAX ID: LOCATION ADDRESS:/3� �/d ,�k ,-� s-�. TEL.#: 5`�8 •S��-�'2� � MAILING ADDRESS: 9. p. j3 ox �8 S. .!/��r-av f�. OWNER NAME: o w� $'� J CORPORATION NAME (ff APPLICABLE): Sc e ��,o.•e_ MANAGER'S NAME: So c 1^•�,•�, � y TEL.#: ,s�n 8 •3 s 7�1 Z C Z MAILING ADDRESS:� o• �d� �3 y i POOL CERTffICATIONS: The pool supervisor must be certi�ed as a Pool Operator,as required by State la�v. Please list the designated Pool Operator(s) and attach a copy of the cei-tification to this forrn. 1. �� 2. Pool operators must list a muiimum of two einployees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Heatth Department will not use past years' records. Yau must provide new copies and maintain a file at your place of business. L 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fiill-time em�loyee who is certified as a Food Protection Manager, as defined in tlie 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 Cle at your establishment. 1. 2. PERSON IN CHARGE: - ` _ _ - — -- — --- _ �_:` - r: Each food establislunent must have at least one Person In Charge (PIC) on site duruig hours of operation. ' ` 1._ �v t j ,'t r-r d.y ��'�/ �t�.t7-�c. 11 2. , HEIMLICH CERTIFICATIONS: All food seivice establishments with 25 seats or more must have at least one employee trained in the Heunlich 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 LODGI\G: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PER1vIII'# LICENSE REQUIRED FEE PERi�1IT� _Bd�B S55 CABIN S55 MOTEL S�5 _L�T:�1 S55 CP,Ii�IP S5� SWI.M1vIING POOL S80ea. _LODGE S55 `TRAII.ERPARK S105 �«'HIRLPOOL S80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT z LICENSE REQUIRED FEE PERb1II'� LICENSE REQUIRED FEE PERMIT� _0-100 SEATS S85 _CONTINENTAL S35 I NON-PROFIT S30 �� _>100 SEAI'S S160 COMMON VIC. S60 �'�'"HOLESALE 'S80 RETAII.SERVICE: —RESID.KII'CHEN S80 LICENSE REQ[.TIRED FEE PER'�IIT# LICENSE REQUIRED FEE PER�VIIT# LICENSE REQUIRED FEE PERi�III$ _<50 sq.Yt. S50 _>25;000 sq.ft. 5225 _VENDING-FOOD S25 _Q5,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO 5» �a�E c�`cE: sis AMOUNT DUE _ � 30,o� *****PLEA5E TL'R\OVER A\D COviPLEI'E OTHER SIDE OF FOR�Z***** 4. � 3 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. 'I'HE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SI�NED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNEU 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 M4�I.S AN� Q'TH�R LODG�I�ESTA�LIS�14^�ENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 sha11 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 Healt�Department to schedule the inspection three(3)days � pnor to operung.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected I 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 ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to operung. 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: O��i�e-�f�s�;o�d��-se�ting with waiter/waitt'�ss.serv�ce),must ha�re�rior approval fram t1�eBoard ofHealth. OUTDOOR COOHING: 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 RESPONSIBILII'Y TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLIS�-IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: � �g SIGNATURE: �- PRINT NAME&TITLE: �� ,��, � �i�s,ae,�—}. 10�06'10 r � The Commonwealth o f Massachusetts Departinent of Industrial Accidents MNfeaN�� 600 Washington Street, 7'"`Floor Boston,Mos� 02111 : - Y ,. Workers'Compeesatios Insannee AtRdayit:�'ildiag/PlambiaglEkctricai Goetnctors ` .., ' " AnnHea�t ■R..��tin: P'lease PRi1VT le�blo �� AD name_ i� i-�' �O c� �l� b J . /1 � �`7 o C , h �G -Y.� 'r �as � 5 � c addnss• Nr � �DX �� , - `a � -- ---- — — i � Ot � .... �-r' e: 'V'1 R �d G'1' . � o S'Q $ G7 ssr �- �, sat o: Q�# 3 "��c� work site location(full addnssl_ �I am a tameowner perf'ornung all work myself. Project Type: ❑New Construction�Remodel I am a sole proprietor and have no one wodcing in any cap�ity. ❑Buiiding Addition ❑ I acn an employer providing workers'compensation for my employees wodcing on this jab. ��- . � ._.�--� . _ - _ . , x_. como�uv ame• � ,+�� , _ �aa�: 1 7 /� Y'� a 4 ,�. .� v � �-u � _ , �je�: �� .��. �,# , I am a sole proprietor,geaenl co�tractor,or�omeowner(circl�one)and h3ve hirad the contr<ectors listed below�who have the ollowing workers'compensation polices: �Y��- �I! 1�o J� .,-�- ��- �b �--,,� l� � � � ��: ��: _ �� 1<�2v -- i 38 �i+ �� tesea.ee eo. � -�- i• �' n S'v�` �1 A� < neitc.A� coeouv oaoe: sddress• �' o�o�e N . _ __ ___ _ _ _ ___ . _ --_ _ ..-- .-` �_ _ _ ,_ imea�ce ea ooLi�� I �wr.ur.w.er..a..r� , Fail�re 0�secm a►aase as reqafral��dv SMM�2SA�t MGL 132 ea�le�d b tre tnp.,p�...tai.�p�,�,.t.m.e�a si,s�N..ai.r o�e pean'IePrYoiwt a�wd as elvi pesakks le the fir��ta 3TOt WdRK ORDLR a�d�Aee af�lOS.N�day a6alat�e. 1 oideneud that a c�py a[tib�fa�ese�my be firwarded 0�Me OQIoe�Imstl�atl��s�t 1Ye DU far aven�e viridatl�r. /do beneby certffy rader NYe p�lws and pen�rhlu ofPerJa►�'�lYat tAie laforiwa�loe provldel aboae fs tnre awd c»nrct SiBnat ` � Date _ ��a��1) Print nartx Phone� ofBelal ex oNy do eat wrlte L thN arca ta 6e covP��Y�Y�Mwn sBkhl ` ` city or towo• ' �°x K ❑BaYdisa Depar�ent ❑ched�ff immediale me b ��t Beard n�ps re9�red ps�.�.•s ckea O� �m��,� �N: �� c ACORD,� CERTIFICATE OF LIABILITY INSURANCE °"�3n`""o,°i'�"' THI3 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER7IFICATE HOLDER. THIS CERT'IFICATE DOES NOT APFIRMATIVELY OR NEtiATiVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THI3 CERTIFICAT� OF INSURANCE DOES NOT CON3TITIJTE A CONTRACT BETWEEN THE IS3UING INSURER(3), AUTHORIZED REPRESENTATIVE OR PRODUCE AND THE CERTIFICATE HOLDER. IMPORTANT: If the certNicate holder is an ADDITIONAL INSURED,the polky(lea)must be endorssd. If SUBR06ATION 13 WAIVED,subject to the terms and conditlons of the polfcy,certain policies may requlre an endo,sement A statement on this certlflcate doea not coMer righta to tl�e certlNeate holder in Ileu ot such endorsomen s. Pnoouc� ►�; Cheryl i'ettibone KbK Insurence(iroup,inc ��N��. 800-TS6-7358 ��; 1712 Magnavox Way P.O.Box 2338 ' ��: Cheryl.Pettibo�kandklnsurance.com Fort Wayne,IN 46801 q�$�R�� wsur�ws►�oRow+c;covEw►c� rin�c r a�su�u w�Ra National Casua n Babe Ruth League,Inc. u�suaER e: Nadonwide Llf�Insurance Co. YARMOUTH YOUTH CAL RIPKEN LG.,INC. q�su�t c: P.O.Box 841 . ursur�o: South Yartnouth J�M, 02664 COVERAGES CERTiFICATE NUIII�ER: REIASION NUMBER: INDICATED. N0TIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE AAAY BE ISSUED OR MAY,PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREM IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� 7YPE OF INSURANCE INSR YYVD POLICY NUMBER LMARS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocGrretice $�� CLA�MS-MADE �OCCUR MED EXP(My one persa�) $ 5,000 q KRO-13871-00 12:01AM 12:01 AM PERSONAL 8�ADV INJURY S 1,OpU,000 02/18J2011 02/01/2012 GENERAL AC3GREGATE NONE GEN'L AGGRECaATE LIMIT APPUES PER: PRODUCTS-COMPAOP AGG f��QQ�,QQQ POLICY PROJECT LOC PARTICIPANT LEGAL LIABILITY $'I,OOO,OOO AU7011AOB�.E L114BILJTY �� $�,QQQ,QQQ ANY AUTO BODILY INJURY(Per person) ALL OWNED AUT0.S BODILY INJURY(Per accident) . A SCHEWLEDAUTOS KRO-13871-00 12:01AM 12:01 AM 02/t8/2011 02/01/2012 Pe�e�� X ►UREDAUTOS X NON-0WNEDAUTOS tMABRELLA LIAB O�UR EACH OCCURRENCE EXCESS IJAB CLAIMS-MADE AGC,REGATE DEDUCTIBLE RETENTION AND EMPLOYERS'LIA6LITY Y/N TORY LIMITS OTHER ANY PROPRIETORSHIPIPARTNER/ � ' EXECUTIVE OFFICERlMEMBER N�A E.L.EACH ACCIDENT �XCLUDEO? E.L.DISEASE-EA EMPLOYEE tM�a�qtwy NI NH) Ryea desta�e under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY UMIT PARI1C�ApIT ACCIDENT B SPP38186-00 12:01AM 12:01 nnao $ 10,000 02/18l2011 ��1�/2�12 PRIMARY MEDICAI $ 250,000 oEscwP�+oF orer��s�wcnnows i v�ia.ea�nmcn�o+o�,na�ao�wm.n�s saw�e,a mor.a�.ee�s nywr.a� Addidonal Insured: My Person,Organizatlon,or Entlty who is en�aged in providing the premises,is a sponsor or co-promoter,but solely witl��peet to the operations of the named insured. CERTIFICATE HOLDER CANCELLATtON SHOUID ANY OF THE ABOVE DESCWBED POLlCIES BE CANCELLED BEPORE EVIDENCE OF COVERAGE TFIE EXP�tp710N pA7E 71�REpF, Wpi10E WILL BE DELIVERED IN ACCORDANCE YYITH THE POUCY PROVISION3. AUTHOR�D REPRESENTA7riE �/f�� ' ' l ACORD 25(Z009/09) �4t'988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered qparks of ACORD '