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Home My WebLink AboutApplication and WC � � –'. _� _=.f.:v �� TOWN OF YARMOUTH BOARD OF HEALTH Ma� ��0�3 � � APPLICATION FOR LICENSE/�!�T2M ��1�'�3 I 7 p�'. "a �— ,� � :. H"' TH QE ' ! Please complete form and attach a11 necessar�G��oc�.tments by De�mbe ! Failure to do so will result in the return of your application packet. ! ESTABLISHMENT NAME: � e r�.h. ��Q.Gi �� a TAX ID• �- ' LOCATION ADDRESS: �Q 8 �- � 1,� ��-�t� u,� e>�-�TEL#• S� 3z/s ��so '' MAILING ADDRESS: S' �r� '� OWNER NAME: t'h r�-��-1� i--��- �'� CORPORATION NAME(IF APPLICABLE): ', MANAGER'S NAME: (�2�.'d�z O c%- �� TEL#• c��3�lS� c.�� ' MAILING ADDRESS: POOL 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. 1. �� -�.�#� S v� k�•�-�� 2. : � Pool operators must list a minimum of two employees current.ly certified in basic water safety, standard First Aid � and C'ommunity Cardiopulmonary Resuscitation (CPR). Please list these employees 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. �i�, l�.u^w� S,:�I �►�-� 2. � 3. �►'Y?��rL�. �.,d. �.�.�z 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• 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 a11 times. Please list your employees trained in anti-chokmg 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. l. 2• 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: � i LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _CABIN $55 C MOTEL $55 ��(3��3 i — i INN $55 CAMP $55 _SWIMMING POOL $80ea. I LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 � >100 SEATS $160 COMMON VIC. $60 _WHOLESALE $8Q : RETAIL SERVICE: —RESID.KITCHEN $80 I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQLJIRED FEE PERMIT# � _<50 sq.ft. $50 >25,000 sq.R. $225 _VENDING-FOOD $25 _ I _<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 _ I, NAMECHANGE: $15 AMOUNTDUE _ $ �� j *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � � . . � ADMINISTRATION 4 X ` Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' � of any license or perrnit 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 SE 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 = i � 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, sha11 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. Conta.ct the Health Department to schedule the inspection three(3)days prior to opening. PLEASE NOTE:People are NOT allowed to srt in the pool area until the pool has been inspected � and opened. 4 PO4L 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 _�u�mit�e�i�o_the Health_]�epartment. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until ti�e 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. i i OUTDOOR COOKING: I Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' i 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, 2012. ALL RENOVATIONS TO ANY FOOD E TABLISHMENT, MOTEL OR POOL (i.e., PAlNTING, NEW EQUIPMENT,ETC.), MUST BE REPORT O A D PPROVED Y THE BOARD OF HEALTH PRIOR TO COMMENC��ENT. RENOVATION Y QU RE A SIT AN. , DATE:�� C�r�� SIGNATU : � PRINT NAME & TITLE: - � Rev. 10/09/12 I � � i CERTIFIC�►TE OF LIABILITY INSURANCE DATE�MMIDDIYYYY) 05/22/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERA6E AFFORDED BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COdTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIYED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certiFcate does not confer rights to the certificate holder in lieu of such endorsement(s). VRODUCER � PAUL SCSLEGEL INSURANCE NAME: SCHLEGEL INSIIRANGE BRORERS INC VHONE 506-771-8381 508-771-0663 ac,No,e,n�: tac,No1. 34 MAIN ST$EET ^ SCHLEGEI.INSURI�INCE@VERIZON.NET ADDRE33: �''ST Y��H � �2673 . CU8TOMERID#: � INSURER�B)AFFORDiNG COVERAGE NAIC q INSURED INSURER A TRAVELERS Bridqe Over Corporation � INSURER B: i sxnnx�xxx x�x� . INSURER C: . INSURER D: Aolbrook, N� 02343 �NSURERE: � � � INSURER F: - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: • THIS IS TO CERTIFY THAT THE POIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE� NAMED ABOVE FOR THE POLICY PERInD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THlS CERTIFICA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR � t7R TYPE OF INSURANCE �Ngp �p POLICY NUMBER (MMIDD/VWY) (MMlDDIYYYY) ��M�T$ GENERAL LIABILI7Y . . . � EACH OCCURRENCE 5 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurtence) 3 -�� CWMSMADE ❑OCCUR � MED EXP(My one penon) S � i �PERSONAL 8 ADV INJURY S � GENERALAGGREGATE E ' GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG S POLICV JECT �� 5- �.. AUTOMOBILE LIAWLI7Y . � COMBINED SINGLE LIMIT E '� (Ea aceideM) �.. ANY AUTO. � .. . � BODILY INJURY(Per persoo) S �� ALL OWNED AUTOS � BODILY INJURY(Per accitleM) E � SCHEDULEDAUTOS � PROPERTYOAMAGE � $ � M�REDAU7QS. � . (PeratcideM) . NON-ONRJED AUTOS � . a � $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S � � ' EXCESS LIRB CLAIMSh1ADf � AGGREGATE � E � � DEDUCTIBLE � $ � RETENTION - S - S ,'�A WORKERS COMPEN8A770N oPC-000978043 . 05/22/201 05/22/2014 TORY LIMITS ER � � AND EMPLOYER8'LIABIIITY � �,��N � ANYPROPRIETORIPARTNERIEXECUTIVE � E.L.EACHACCIDENT S SOO�OOO � OFFICERIMEMBER EXCLUDED9 ❑ N�A ' (Mandatory in NH) - E.L.DISEASE-EA EMPLOYEE � S 1 O O�O OO � It yes,tlescribe untler - DESCRIPTION OF OPERATIONS below ' E.L.DISEASE•POLICY liM1T E 5OO�OOO . . DESCRIPTION OF OPERATONS/LOCATIONS/VEHICLES(Attach ACORD 701,AAAitlonal Remarks 8cMdule,if mon spau ia requirod) . � CERTIFICATE HOLDER CANCELLATION CAPL TRAVELER ': B�Cg �Y SHOULD ANY OF THE ABOVE DESCRiBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTiCE WILL BE DELIVERED IN �Y ��R I� ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEp REPRESEN - SAND DELIVERED 88-2009 ACORD CORPORATION. Ail rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered m rks ACORD 1 1 � � . CERTIFICATE OF LIABILITY INSURANCE oA�IMMIDDIYYYY) 05/22/2Q13 � THIS CERTIFICATE IS ISSUED AS A MATTER OF iNFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES � BELOW. THIS CERTIFf�ATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORI�D � REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate hoider is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statemeM on this certiflcate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER PAIIL SCHLEGEL INSIIRANCE NAME: SCHLEGEL INSIIRANCE BROKERS INC pHONE �ac,No,eM: 508-771-8381 �ac,NoJ508-771-0663 34 MAIN STREET E�A�� SCSLEGELINSIIRANCE@VERIZON.NET ADDRES3: WEST YARMOIITH MA 02673 CER CUSTOMER ID#: INSURER�3)AFFORDING COVERAGE NAIC# INSURED INSURER A�J.'RAVELERS � Bridge Over Corporation INSURER B: 1 SIDDHARTH LANE INSURER C: � INSURER D: Holbrook, I�+, 02343 INSURERE: INSURER F: � � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POIICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTR,4CT 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. '�TR INSR NND � POLICY NUMBER POLICY EFP PO C UMI75 TYPE OF INSURANCE (MPNDDM(VY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABII.ITY PREMISES(Ea occurrence) $ CLAIM6MADE ❑OCCUR MED EXP(My one person) $ . PERSONAL&ADV INJURY $ � GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: � PRODUCTS-COMP/OP AGG $ POLICY PR� LOC $ JECT AUTOMOBILE LIABILJTY COMBINED SINGIE IIMIT $ (Ea accitlent) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY�(Per accitleM) $ SCHEDULEDAUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLALIAB OCCUR � EACH OCCURRENCE S � � EXCE53 LIAB CIAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ . $ A WORKERSCOMPENSATION WC-000978043 05/22/201305/22/2014 WCSTA U• - AND EMPLOYERS'LIABILITY � TORY LIMITS ER ANV PROPRIETORIPARTNERIEXECUTIVE Y�N E.L.EACH ACCIOENT $ S OO�OOO OFFICER/MEMBER EXCLUDED? ❑ N�A (Mandatory in NH) . E.l.DISEASE-EA EMPLOYEE $ 1 OO�OOO If yes,tlescribe under DESCRIPTION OF OPERA710NS below E.L.DISEASE-POLICY LIMIT $ S OO�OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attath ACORD 101,AtlAitional RemaAcs Schedule,ff more space is required� � CERTIFICATE HOLDER CANCELLATION TOWN OF YARMODTH ROUTE ZH SHOULD ANY OF THE ABOVE DESCRIBED POLlC1ES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WEST YARMOUTH� MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS. . AUTHORIZED REPRESENTATiVE HAND DELIVERED �O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered ma f ACORD