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Home My WebLink AboutApplication and WC � ` � �1�:��uC?�D S. � � TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LIC�?YSE/PERI�IIT -2016 MAY 13 Z O�6 ''°° * Please complete form and attach all necessaxy doc �ec� ber 1 S 201 S. retur�-'of o�r�tion a ket F Fa�lure to do so will result in the y � p H�ALTH DEPT. ESTABLISHMENT NAME: �3�g •y �i�� s�e'i� i�TAX ID: � -�� ' LOCATION ADDRESS: D' - ' �1� �� '/t � ac�� a� EL.#: ' �-� '>��' MAILING ADDRESS: �cJ .�.�i'�1.5iDr%�'/.�� j✓� �/�f'v1�QCC� �1� E-MAIL ADDRESS: ��. �i RS�An'.�c � ��/'� � ��2f'1 OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGF,R'S NAME: TEL.#: E/ ��c�5' r 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. _"___-_._ . _ / /x�/J -- - � .�� , 1• � � I�1��'� 1J I �f __ _ � � �u zi� TT�_ _ 2. _ _ - -__ _- _ 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.��1" ��l`6�� ►'1�i.�l � 2. 3. 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� _ . _ � -- __ _ _ --- ALLERGEN CERTIFICATIONS: ' All 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. L� � � 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-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. 1. /�� 2. 3. 4. RESTAURANT SEATING: TOTAL# �--- --- — -_ ____ _ _8�r�iC� �ia��i��--- - -- ___ --------— _ LODGING: LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 �SWIMM[NG POOL$i l0ea.�� LODGE $55 TRAILER PARK $105 _WHIRLPOOL $1 l0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >l00 SEATS $200 COMMON VIC. $60 WHOLESALE $80 _ — — �RESID.KITCHEN $80 RETAIL SERVICE: LICENSE 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: $15 AMOUNT DUE _ $ SI�E� //C�-� *****PLEASE TURN OVER AND COMPLETE OTHER S1DE OF FORM***** , i �t 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 1VIUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio 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 Yartnouth 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.varmouth.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 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 REQU SIT LAN. DATE: „S�� "�� SIGNATURE: � ��'—r'�—� , PRINT NAME & TITLE: �L`� ��j}„�',��"��' ,/r`�y��t��c�� Rev. 10/O 1/I S A� CERTIFICATE OF LIABILITY INSURANCE 05/01/201�6�) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA110N ONLY AND Ct?NFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEC.aATIVELY AMEND,EXTEND OR ALTER THE COYERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE tSSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT=1f the certificate holder is an ADDIl10NAL INSURED,the policy(ies)must!�endorsed. If SUBRQGATION IS WAIVED,su6ject to tl�e terms and conditions of the policy,certain policies may require an e�doraemeM. A statement on this certificate does rwt confer rights to the certificate halder in lieu of such endor s- PRODUCER CONTACT Paychex Insurance Agency inc PAYCHEX INSURANCE AGENCY,INC. PNONE F� 150 SAWGRASS DRIVE - 8T/-�� • 585-389-742s ROCHESTER,NY 14620 E-�� Certs(�?paychex.cam INSURER(S)AFFORDING COVERAGE NAIC#� INSURED INSURER A: No1GUARD Insurance Company 31470 HEAVENLY POOLS INC. INSURER B: 119 PQND VIEW DRIVE CEIYTERVILLE,MA 02632 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFlCATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE PqLIC1ES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FQR THE POLICY PERIOD INDICATEO.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH 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 REWCEO BY PAID CLAIMS. 7YPE OF INSURANCE R POLICY NUMBER �Y� ��Y�P V�TS TR (�) (M�Y�) GENERAL LIABILITY EACH OCCURRENCE S C�FAMERCIAL GEPIERAL L1ABIl[TY DAMACaE TO RENTED $ � �Cl.A1MS-MADE�OCCUR MED EXP(Arry me�rs�) g � PEASONAL&ADV�IJURY ; GENERALAGGREGATE $ EN'L AGGRECaATE UMff APPlIES PER: � PRODUCTS-COMPfOP AGG $ POLICY �PRO.ECT�[AC $ AUTOMOBILE LIABIIITY �NED�'"��"T a ��a��„� Anrc aur0 BODILY INJURY .,�o�m,�o �sc�,� �r�,a�,�„r a nuros nuros . O�W �DIL�Y��)RY � � Hlfl�AUTOS A � . � PROPERTYDAMAGE � . . . (Per accideirt) $ UY��R EACH OCCURRENCE $ ocCESSIue �Cun�1sMADE AGGREfATE y DFD fiEiENTIONS $ WCSTATU- O7H- �o�,W��°A"o HEWC752311 45l18/2016 05/18/2017 X EL EACH ACCiDENT S ��.�•� ANVPROPRIETORIPARINERIEXECUiNE o�iCEw�n�t9ER Exc�uoeo? E.L DISEASE-EA EMPLOYEE $ 100,000-00 (w��y y�� N/A EL DISEASE-POLICY LIMIT $ 500>000•� M yes,tlasvbe Wer nesc�arna�oF o�aAno��wcarro►u i v�Kxes tatmd�ncopo�o�,�aauo��s�n�,�e,n��r�� CERTIFICATE HOI.DER CANCELLATION EPIGLEWOOD BEACH RESORT ��THE ABOYE DESCRIBED PO1-ICIES BE CANCELLED BEFORE TME EXPIRATION 60 BROADWAY oAre ni�oF,Nonce wu ae oeuveaEo�nccoeoaNce wmi nie roucr W EST YAFIMOUTH,MA 02673 PRO�S�BUT FAIL�RE TO WLL SU�M�7�E SHALj'�MPOSE NO O&JC'aT10N OR LIA8�17Y OF ANY IQ16 Uf+ON iHf COMP/WY,(fS AGENTS OR REPRESENTATIVES AUTHQRIZED REPRESENTATIYE � _�J� '�� _ '.� ACORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENGLEWOOD BEACH RESORT 60 BROADWAY WEST YARMOUTH, MA 02673 ACORD 774670 0012/0012G806