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Home My WebLink AboutApplication and WC , �—.�<��- a + 9 � - TOWN OF YARMOUTH BOARD OF HEALTT.� �:�� APPLICATION FOR LTCENSE/PF��T�Qi .� , � _� � � � , -� �� NOV 17 2009 *Please complete form and attach all necessary doaun�nt�-hq ece � -� - i Fail,ure to do so will result in the return pf yaur application pa tr�. i �.��..�.....�..,.��.�.. � NAME OF ESTAI�LTSHMENT:_ A'a'�'le'?f 1 �q� 'Hos� rno i r L TEL. # ��5- ��S=Z33 Z � LOCATION ADDRESS:-- C'n q__ l2��a SS C� �{A�2 M v Lr! N n9 A o ZG� MATLING ADDRESS: � OWNER NAME: - �- FE r CORPORA.TION NAM (IF APPLICABLE): v�av a 2 MANAGER'S NAME: T�.e,rb ,.�� 1�A i�L TEL. # -`6'10 —C�oZy MAILING ADDRES5: `��,�oc��- �g G.� � �912,�✓�oc�?1-1 TYlrr,t �926��, , ��...,,_.��_....�...._�., �. POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Qperatar,as reqaired by State law. Please list the designated � Paal Operator(s)and attach a copy of the certification to this form. 1. _ 2, _ Pool operators must list a minimum o£two emp loyees currently certified in basic water safety,standard First A.id and ! Commuruty Cardiapulmonary Resuscitation(CPR). Please list these employees b�low and attach copies of employee � certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintafn a fi�e at your place of business. �. a. 3• 4. ��I��I�A��I�I��q��l��ll FOOD PRbTECTION�VIANAGERS - 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 pRst years'records. You must provide new copies and maintain a file at your establishment. � 1• 2. PERSON IN CHARGE: Each food establis�unent must have at least one Person In Charge (PIC) on site during hours of operation. 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 tumes. Please list your employees trained in anti-chakui:�procedures below and attach copies of employee certifications to this form. The Health Department will not use past yQars' records. You must provide new copies and maintain a file at your place of business. L 2 3, 4 RESTAURANT SEAT'ING: TOTAL# LODGING: OFFIGE USE ONLY LIC�NSE REQLTIRED FE� pERMIT# LICENSE REQUIRED FEE PERMIT# LICENS�REQUIItED FBE PERMI'T# .,�BBcB $55 ,_CABIN $55 I MOTfiL $55 �'(D'�� ---�N $55 ____CAMP $55 LSWIMMING POOL S8Uea. �'I0�0�2 ,_LOD4E $55 ,,,_TRAILER pARK $105 / WIIIR.I,POOL $80ea. �I0�00� FOOD SERVICE: LIC$NS$REqUIRED FEE p£RMIT# LICENSE REQUIRED �'�E PERMIT# LICENSE REQUIRED FEfi PERMIT# �0-100 SEATS �85 .,LCONTINENTAI, $35 � 0-6'?�-� �NON-�'ROFIT $30 >100 SEATS $160 �COMMON VIC. $60 rtWHOLESAL� $80 RET.�IIL SERVICE: _.._RESID.KITCHEN �80 LIGENSE REQUIRED FEE PERMtT# LICBNS�REQUIRED FEE P�RMIT�# LIC£NSE REQUIRED FEE PERMTT# ! _,<50 sq.ft. �50 _>25,000 sq.ft. �225 ____VENDING-FOOD $25 I ,,,,",<25,000sq.ft. $80 _,.FR,OZENDESSERT $40 �TOBACCO �55 N��G�: $i� AMOUNT DUE = S �„50,oo f •"*""�LEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM � »*.,.«, � � � ��. , t �_.,..:� / : . , . � , ! . f .... , .._ .. I : . �, ; �� ,.. . . . b'� ' �k � ADNIINISTRATION ' ` . � Und�rC�apt�x 152��Sectipn 25C, Subsection 6,the Tawn of Yumouth is now required to hold issuance or renewal of any"license or pErmit to operate a business if a person or company does not ha.ve a Certific�.ta of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION: 1NSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSUitANCE ATTACHED� . . ' OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ' � Town of Yarmouth taxes and liens xnust be paid prio o renewal or issuance of your permits. PLEASE CHECK � APPROPRI�TELY IF PAID: � � YES ' NO � MQTELS 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, ordinaril�and customarily associated with mote2 and hotel use. Transient occupants must have and be able to demonsixate thax they ma,intain a principal place afresidence�lsevvhere. Transient occupancy shall generally refer to continuous occupancy of nat more thar► t�rty (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 Raom Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transi�xt. _ � POOLS i POOL OPENING:All swimming,wading and whirlpools which ha.ve been closed for the season must be inspecteci by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3)days t pnor to opening.PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has been inspected and opened. � PO4L WATER TESTIl�TG: The water must be tested for pseudomonas,tatal coliform and standard plate count i 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 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 forcns can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the s�uspension ar revocation of your Frazen Dessert Pennit 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 ofHealth. OUTDOOR COOKING: Outdoor caokt•ng,preparatio�or di�ay of an_�food product by a retail or food service establis_hment is p_rohibited. _ _ N4TICE:Permits run annually from January 1 to December 31. IT IS YOUR RESP4NSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. � ALL REN(JVATI4NS TO ANY FC10D ESTABLISEaViEENT, MOTEL OR PDOL (i.e., PAINTING, NEW ` EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD 4F HE.ALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLA � J� � � [ ' DATE: /� � SIGNATURE: / � f , � �^ � { PRINT NAME&TITLE: �� V C! �1� ,/ �/ - � i , � , 09l25/09 fi . �_ �� Nov, 13. 2C09 �: 13P Vo, 203? ', 1/2�� '' • A�(;urru ��r�TIFICATE OF LIABILITY INSURANCE TM 11/13/2009 � PRODUCER 508.997.6061 FAX 508.990.2731 THIS CERTIFICATE 151SSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 439 State Rd. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 North Dartmouth, NA 02747 INSURERS AFFORDING COVERAGE NAIC# iNsu�o MESHIYA Corp in�s�ReRA: Harleysville Worcester Insuran DBA: American Host Motel INSLRERB: 69 Main St INSI,RERC w Yarniouth, MA 02673 INSLRERD' INSLRER E: COVERAGES 7HE POLICIES dF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING i ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EJ(CLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICYEFFECTIYE POLICYEXPIRATI�N LTR NS �E OF INSURANCE POLICY NUMBER OATE M1D �ATE MID LIMfT3 c�Ner�uuaeiu�v GL2M2956 06/28/2009 06/28/2010 EACHOCCJRRENCE $ 1,0OO,OD X COMMER�Ir�1 GENER?L LU1B LI1' PREMISES E3 occ�rrence' $ IDO,OD CJUMS A4RDE �O�CUP. A1ED EXP(Rny one person) $ 10,QQ A PERSONAL&AQV INJURY $ 1,OOO�OO GEWERAL RGGR=GATE $ Z�OOO,OD GE�'L.46GP.EGATE LIMIT PPFLIES PER: PRODJCTS-COMPlCP AGG $ Z,ODO�OD P�LICY jEa LOC AUTOMOBILE LUqBILITY BA2M2956 06/28/2Q09 06/28 j2010 COW181NEDSINGLELIMIT $ AVY AUTO (=a accidert) 1�0�4,OD F�L OWPED AUTOS BODILY NJUP,Y � A S�FEDULED AUTOS � ('e�p=reon) $ X HIREDAUTOS BODILY NJURY X N�N-OJVNED AlJiOS ('e•a�citle�t) $ PROPERTY DAM4GE $ (�e-a�ciden) I�� GARAGE LIABLITY hUTO ONLY-EA Ar_CIDENT $ : AVY AUTO OTHER THAN EP.ACC $ �.��.. � �UTO ONLY� AGG $ � ExCE331 UMBRELLA LUIBIL(TY EACH OCCJRRENCE $ OCGUR �CJUMS MIP.DE AGGR-GATE $ $ I DECUCTI3L= � $ � . R-TEIYiION $ $ WORKERSCOkQENSATI�N WC2M2961 OS�OL�ZOO9 OH�OZ�ZOLO X TORYLIMIITS ER AND EMPL�VERS'LIABILffY Y/N ANY PROPRIETOR1PARl1VER/EXECt1rIVE ❑ E.L E4CH ACCIDINf $ SOO,OD A OFFICER/MEMBER EXC_U7ED'.+ (Mandatory in NH) EL DISEASE-EA EA4PLOY $ 5D0,�4 If y�s,describe�nder SPECIAL PRQVISIONS below EL DISEA3E-POLICY LIMIT $ S�O,OO OTHER � ��. f OESCRIPTION OF OPERATIDNS!LOCA110N3!VEHICLE31 EXCLUSIONS ADD�BYENDORSEMEIYTf SPECIN.PROVISI�NS � . CERTIFICATE HOLDER CANCELLATION SHOULO ANY OF 7HE ABOVE DESCRIBED POLICIES BE CANC�LED BEFORE THE EXPIRATION UATE THEREOF,THE ISSUING INSUR92 YVILL EN�EAVOR TQ MAIL DAYS WRITiEN TOYW'1 of Yarnwuth NOTICE To THE CERTIFICATE HOLDER NAMED TO THE L�T,BUT FAILURE TO UO SO SHALL Board Of Heal t h IMPOSE NO OBLIGATIqJ OR LU►BILRY OF ANY NIPO UPON THE INSURER,IT3 AGENTS OR Rte. 28 REPRESENTATIYES. Yarnauth, MA AUTHORI�DREPRESENTATiVE Krista Hartford ACORD 25(2009l01) O 1988-2009 ACORD CORPORATION. All rights reserved. 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