HomeMy WebLinkAboutApplication and WC __ .� �_-
' � � TOWN OF YARMOUTH BOARD OF HEALTH � -��
� � APPLICATION FOR LICENSE/PERMIT - 2012, �:-,�5 - �, . ., .
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�� * Please complete form and attach all necessary doc�e -` e '` B,�_ �r
Failure to do so will result in the return of your�ppl��c�g�c t. ����:.
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ESTABLISHMENT NAME:A1�I�►Or�,u�S �wr►r�49�� �ri ,��tG TAX ID•
LOCATION ADDRESS: � a�-M o� TEL.#: -31�"�ISC3
MAILING ADDRESS: lern c �1
OWNER NAME:
CORPORATION NAME(IF APPLICABLE): ` r► ,
MANAGER'S NAME: TEL. : �' ��
MAILING ADDRESS: i
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
- ��c�l �J�erarc�r(s) and at±��Y�� ��z s�€�sertifi��tion to this form. _ _
L 2.
Pool operators must list a minimum of two employees 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 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.
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.
1. 2.
PERSQN IN_('HA�2GE: _ __ . . - --
- -- - __
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
1.��("�QF � �,� 1C: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#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
�liv�v $55 0���'�7 _C:.�'�i� $55 _SWiMIl�IINi�P�UL $2S�ea.
_LODGE $55 _TRAII,ER PARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMI'C#
_0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30
�>100SEATS $160 �a'���7 �COMMONVIC. $60 �l�-n33 _WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25
_Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $is AMOUNT DUE _ $ �--�S•�v
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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 1ViL1ST BE COMPLETED t�ND SIGNED, OR
CERT. OF INSUR�NCE ATTACHED
. OR
WORKER'S COMP. AFFIDAVIT SIGI��LD AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your per�iits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
Ii�IIOTEI.S A��1D f�'I`HEIt L()llGil��i(i�S`�°Af3LIS�li�iEN�":�
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 m 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 groun.d swimming pool must be drained or covered within seven(7)days of
closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPElVING:
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
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:
_ ��1r�;�P r���c,P.;�>>t��;�Q�+���.t7�����,airP.r/s?v�itrPsc S�rV1CP.);m�.i�t have nrior anproval 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 REQUIl2ED FEE(S) BY DECEMBER 15,2011.
ALL RENQVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO CUMMENCEMENT. RENOVATIONS MAY REQUIRE A SIT�.PLAN.
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DATE: o� I SIGNATURE: �:���-,'��� ,.�'� _��
PRINT NAME &TITLE:_};r�'1�@p �v� 1��l�C�r �E'��
Rev.10l25/11
Aca"� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D0/YYri�
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THIS CERTIFICA7E IS fSSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIHCATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITIlTE A CONTRACT BETiNEEN 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 WAIVED,subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement s.
PRCDUCER ���CONTACT
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KIRKILES 8 ASSOCIATES �,v�,No,Ex,1 781-659-3300 _____ k�x Na 781-659-3366
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COMMERCIAI INSURANCE BROKERAGE LLC ti oREss
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273 RIVER STREET ,rvsuReRis>ArcoRo,r:�covEtu�E �..a.c a
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NORWELL,MA 02061-2209 �hs�itER a MASS RETAIL MERCHANTS
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YARMOUTHPORT, MA 02675 �ysuRE�E
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COVERAGES CERTIFICATE NUMBER: 100338 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POIICY PERIOD
iNDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFIGATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCWSIONS AND CONDITIONS OP SUCH POUCIES UMITS SNOWN SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS.
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DESGRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AqaM ACORD 101,Atlditional Remarka Schsdule,i1 more apace is reqWroa) �
CERTIFICATE HOLDER CANCELLATION
TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE OESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRATION �ATE THEREOF, NOTICE WILL BE DELIVERED IN
HEALTH INSPECTOR ACCORDANCE WITH THE POIICY PROVISIONS.
99 BUCK ISLAND ROAD
W. YARMOUTH, MA 02673 AUTHORRED REPRESENTATNE
FAX: 508-760-3472 '1���
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O 1988-2010 ACORD CORPORATION. AII rights reserved.
ACORD 25(2010/05) The ACORD�ame and lago a�e registered marks oi ACORD
DEC-02-2011 11�50 ANTHONY'S PIER 4 7815�89321 P.02
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CERT�FrCA7E b0E3 NOT AFFIRMATIVELY OR NEGe►nvE�Y aMENd, EX7END OR ALTEF�7HE COV�{rR(i�.�FFOFtD�Q,�,'17i�PL�LICIEB BELDIIY.
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REPRESENTATIVE OR PROOUCER,AAlO THE CERT(FICATE HdLDER. '
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COVERAGES CERTIFICATE NUM��R� 100338 �
THIS IS TO CEATIFY T►iAT TNE POUGES OF INSURANCE USTEO BELOrN HAVE BEEN ISSUED TO THE�N U p " � OI,CY PERIOD
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CER1'IFICATE HOLDEft CANGELLATIpN ` ` � '�:+"'
SNOULO ANY OF THE AQOVE,���9�0;�'���CAM¢E4LED BF.�OItE
TOWN OF YARMOUTH THE exPut�noN O��'E,`,77}� yc�nc� ��i', ge D��NER�p IM
H�AL�TH INSPECTOR ACCORDANCE WITH TNR�PDLfCY'PRO��WM18t'�.;,:'�f:� '°`'���
99 BUCK ISLAND ROAD � '>
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W,YARMbU7H.MA 02673 AU�NOR¢ED REvqESENTATNH � � ' / ;
FAX:508-760-3472 �,����
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cooperation is g'eatly appreciated.
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