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Home My WebLink AboutApplication and WC �; ��..�w. 'i1'��i'7'?tQMy..s.� ' TOWN OF YARMOUTH BOARD OF HEA��,T� �"� � � APPLICATION FOR LICENSE/�;��IT- 2a11 - ' , �010 : , , � .,�e � * Please complete form and attach all necessary doc ' s� y Dec mb �- � 0 v Failure to do so will result in the retur�..�f your application v' ` ��"� ESTABLISHMENT NAME: /I ��J 2� L/I o TAX ID� `' '� � LOCATION ADDRESS: — � TEL. : '�c� MAILING ADDRESS: �J�p'D OWNER NAME: ^ CORPORATION NAME (IF AP LICABLE): J C% � MANAGER'S NAME: TEL. - 'D -'� MAILING ADDRESS; �-- POOL CERTffICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poo1 Q�erator(�)_aucl atta_ch a_copy_Qf tJl� certifi�arioii_to this foi7n. 1. 2. Pool operators must list a inuiimum of two employees cun ently certified in basic��ater safety,standard First Aid a�id Community Cardiopulmonaiy Resuscitation(CPR). Please list these employees below and attach copies af employee certifications to this form. The Health Department will not use past years' recards. You must provide new copies and maintain a file at 3�our place of business. l. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTffICATIONS: All food service establislunents aze requued to have at least oiie fiill-time employee who is certified as a Food Protection Manager, as defined ul the State Saiutary Code for Food Seivice Establisluneuts, 105 CMR 590.000. Please attach copies of certification to this application. The Aealth Department�vill not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: �ac1i taod establisIunent niust l�ave af least�orie Yerson In Cl�arge (F1C) on si�te during llouis of operation. � L 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained ui the Heimlich Maneuver on the premises at all tunes. Please list your employees trained in anti-choking procedures below and attach copies of em�loyee certifications to this form. The Health Department wilt not use past years' records. You must provide ne�v copies and maintain a �le at`�our place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE OlV'LY LODGI\G: LICENSE REQUIRED FEE PERIVIIT# LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERibIIT# B&B S�5 CABIN S�5 140I'EL S55 �INN S�� I�WSP _CA_MP S5� _S�U1�/LvIINC POOI_ cgpea- LODGE S55 TRAILERPARK S10� WHIRLPOOL S80ea. FOOD SER�'ICE: LICENSE REQi7IRED FEE PERMIT� LICENSE REQUIRED FEE PER�IIT# LICENSE REQUIRED FEE PER�IIT� 0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 �>100 SEATS S160 � ��-0�41 1 CO'_VL�ION VIC. S60 � ��'HOLESALE S80 RETAIL SER�'ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�1IT� LICENSE REQUIRED FEE PER�2Ir� LICENSE REQUIRED FEE PERVIIT?� _<50 sq.t�. S50 _>25,000 sq.ft. S225 _VENDING-FOOD S�� _<2�,000 sq.ft. S30 _FROZEN DESSERT S40 _TOBACCO S» ��v�E c�`cE: sis � AMOUNT`DUE _ $ a'75.o 0 ***�*PLEASE TtiR\OVER A�D CO�IPLETE OI'HER SIDE OF FOR�f****" _ y r , ADMINISTRATION .� � Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut 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 BE COMPLETEID AND SIGNEn, OR. CERT. OF 1NSURANCE ATTACHED OR WORKER'S COMI'. AFFTDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO i�v��r i�i�AN� Qr`�r:l�Lu�iTITV G L�7i`A1iiLI�H1VIIN:N'�'S TRANSIENT OCCUPANCI': 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. Contact the Health De�artment to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to srt m the pool area until the pool has been inspected and opened. POO1L 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. Pf30L CLUSING: �very 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 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 DE55ERTS: 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 ofHealth. _ _ _ OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohi6ited. NO'TICE:Pernuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY 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 OVED B BOARD OF HEALTH PRIOR TO COMMENCE ENT. RENOVATIONS MAY REQ R SIT ' . —' D4TE: Z � �U SIGNATURE: PRINT NAME&TITLE: '�-k��,�?"'y��,7 (�,� �o«,io ��,� :,�'> v I 4 • �-� `T� �\ The Commonwealth ofMarsachusetts ' � , Deparhnent of Industria!Accidents M�Ni�j{� 600 Washington Street, f"'Floor Boston,Mass. 02111 Workers'Compensation Insarance Affidavit: gnilding/Plambiog/Ekctricai Contractors Annlie�t l•f+•�•••■ti�; Pkase PttINT kQlbh narce: adciress: city state- Z1D' ohare# work site location(fitll address)- ❑ I am a homeowr�er performmg all work myself. Pro�ect Type: �New Constniction�Remodel ❑ I am a sole proprietor and have no one working in any capacity. �gw��ng Addition ❑ I am an employer providing workers'cornpensation for my employees working on this job. _ ___ _____— — -- __ __ _ _ __ . com oamr. address- cttv: �hoae M ins�see ca # ❑ I am a sole�oprietor,general co�tractor,or homeowner(circlt o�u)and have hired the conhactors listed below who have the foilowing woricers'compensation polices: comoanv rame- address• ciri: a�� iesmaoce co. # commev�m.- address: citw o�we N _ . _ _ -- __ _ _ _ ____ _ ___ __ -- -- ��_ _ � # �wdr.++rr.�+ws r� Failare b xeate eerctase a reqdr'ed�edv Scetlo�2SA�f MGL 132 eu idd b t�e fsphitlw derlsral ese yan'Impr6000eat a�wdl as dv�peaaHia ln t6e forr of a 3TOl WORK ORDLR asd��ne d S1a6.0�p a da�y ag imt me�laoeden�ei,d t6at a ropy o[t6h sta�e may be forwarded Qe the ORlee of Iaves�gaW�o(the DIA far c�veraae verleeatlN. !do Are►+eby ce w er Nie polw awd ald�r of pe r�y tl�et t/he lafonrratloh prov�ded abone fs btrt awd rn Signatute . �G Date Print narne T K l� �� V ? • Phone� t� �/� 3��l f�/ "�f-- e�ai nx oely do oM write�thh area to be rnopieted 6y chy or qwa oBkhi city or tewu• PennidHcense 11 ❑Baid�s DePartment ❑eheck if imteediah rc�eme is reqoircd �llceeaina Board �Sd�ectmea'a Ofsee rnntad penoa: 6oae#• �Hakh De�ar�e,t t�a x�zoo�r P O�mer ACORDM CERTIFICATE OF LIABILITY INSURANCE D 11/19/2010 PRODUCER Serial# 3521 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION KIRKILES&ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COMMERCIAL INSURANCE BROKERAGE LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 273 RIVER STREET NORWELL,MA 02061-2209 INSURERS AFFORDING COVERAGE NAIC# INSURED iNsuReR A: MASS RETAIL MERCHANTS ANTHONY'S CUMMAQUID INN, INC. INSURER B: RT.6A INSURER C: YARMOUTHPORT, MA 02675 INSURER D: INSURER E: COVERAGES THE POLICIES 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MM/DD/YY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMI E Ea occurence $ CLAIMS MADE � OCCUR MED EXP An one persan) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY �E� LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR �CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE g � RETENTION $ $ WORKER'S COMPENSATION AND 0140050310081010 1/1/2010 1/1/2011 X TpRY LIMIT ER A EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ rJOO,OOO OFFICER/MEMBER EXCLUDED? EL DISEASE-EA EMPLOYEE $ rJOO,OOO If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ rJOO,OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN TOWN OF YARMOUTH HEALTH INSPECTOR PHILLIP RENAUD NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 99 BUCK ISLAN D ROAD IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR W.YARMOUTH, MA 02673 REPRESENTATIVES. FAX: 508-760-3472 AUTHORIZED REPRESENTATIVE ��.'7�:�..�'� ACORD 25(2001/08) O ACORD CORPORATION 1988