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Home My WebLink AboutApplication and WC _ �, .� .�� - �.�, , ` , � ��7� �,.��_ � � TOWN OF YARMOUTH BOARD OF HEALT � � � APPLICATION FOR LIC ,� �, ' a : : �� 0 Z013 � �� : �� ;.� * Please complete form and attach a11 n�, , ,� ;. e 13. , Failure to do so will result in the eturn o your app ic ' . ' ' ESTABLISHMENT NAME: d�ntiu I • LOCATION ADDRESS: �� S : W arm�� /�k• TEL.#: 5a ��3�-�'� J l ' MAILING ADDRESS: GLYYti E-MAIL ADDRESS: �11�GI3VICC�DS(1� (��,('(�5'�� 'l�" OWNER NAME: �.� ,�� t�-p C�S,�,a,�1 lT� '' , CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: TEL.#: 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`�v� ��v�nj ,��I-4�:�-�� , 1�� . 2. • Pool operators must list a minimum of two employees currently certified in basic water safety, 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. ' L—..�Y�'«� ��-l!�.�V``.� 2. ' 3.� Gt�� (.�YY'C,.� 4. � FOQD PROTECTION MANAGERS - CERTIFICATIONS: �' All food service establishments are required to have at least one full-time employee who is certified as a Food Protection !i Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please atta.ch ;, 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�harge (PIC)on site during hours of operation. 1. 2. _ _ _ � 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. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee 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 certif cations 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. It�STAURANT 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 INN $55 CAMP $55 �SWIMMING POOL $80ea.�Obd-- LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE 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 $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. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: �i s AMOUNT DUE _ $ t(o C)�OC� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' -:.7... _. ` � ! ADMINISTRATION r V 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 Certifieate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ''� i OR ; WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED i I Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK j APPROPRIATELY IF PAID: k YES � NO ' MOTELS AND OTHER LODGING ESTABLISHMENTS ___ ____ _____- -,.__.___- -__ . __ -- _ ______>.:_- _ _ . � ____ � _ ___ _ __-- - --_ -�- -- -- _ ___� TRANSIENT OCCUPANC�: 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 sha11 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. i POOLS POUL��;NING:AII swimming,wac�ing anc�whi�o�w�i�h-have-been��asecl�o ' c�-hy the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People axe 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 Yarmouth Health Department by filing the required Temporary Food Service Application form '2 hours �rior 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: Outside cafes (i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparationzor displa�of any food�roduct b�_a retail o_r__food service_establishment is �rohibited. __; < ; 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 13, 2013. i � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO � COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: I Z` ��I �� SIGNATURE: � � PR.IN"T NA�E&T'ITLE: _ _, �-j �'� ��'Y�-r��rl-Gt� - ' Rev. 10/08/13 C , ,�--�•� BUCKI-2 OP ID:SH ACC?RO" DATE(MMIDDIVYW� ' • �- CERTIFICATE OF LIABILITY INSURANCE 11/2612013 THIS CERTiFICATE IS ISSUED A5 A MA7TER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAl1VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONS7ITUTE A CONTRACT BETWEEN THE ISSUING IN3URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CER7IFICATE HOLDER. IMPORTANT: If the certiflcate holder Is an ADDITIONAL INSURED, the pollcy(les) 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 certiflcate does not confer rights to the certiflcate hoider in Iieu of such endorsement s. PRODUCER Phone:781-247-7800 �E: Rodman Insurance Agency,Inc. Fax:781-444-0090 PHC No Ex : AIC No: 145 Rosemary St.,Bldg.A E-MAIL Needham,MA 02d9d-3238 ADDRESS: Jeffrey Grosser INSURER S)AFFORDING COVERAGE NAIC/ INSURERA:A.I.M. MUtUeI IrISUCenC@ CO. INSURED Buck Island Village Condo INSURERB: c!o Office INSURER C: 481 Buck Island Rd W Yarmouth,MAOZBTS INSURERD: INSURER E: � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINC ANY REQUIREMENT,TERM OR CONDff10N Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIfICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POIICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDI710NS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ��jR TYPE OF INSURANCE � 4YVD PQLICY NUMBER MMIDDIYY MMIDDIYYYY LIMRS GENERAL LIABILITY EACH OCCURRENCE $ � COMMERCIAL GENERAL LIABILITY PREMI$ES Ea oceurrence $ CLAIMSMADE �OCCUR MED EXP(Any one person) $ � PERSONAL&ADV INJURY $ - GENERALAGGREGATE $ GEN'L AG6REGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PR� LOC $ AUTOMOB�LE LIABILITY COM8INED SINGLE LiM1T Ea aaident S ANY AUTO BODILY INJURY(Per person) 3 ALL OWNED SCHEDULED BODILY INJURY(Per eccidenq $ AUTOS !!UTOS -- NON-OWNED . P80aCRa nDAMAGE $ HIRED AUTOS AUTOS � $ UMBRELLALIAB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE AG6REGATE $ DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYER3'LIABILIT' �I'-•-- -Eg- A ANY PROPRIETOR/PARTiVER1EXECUTIVE Y� N t A CiD060026852013A 11l08/2013 11/08/2014 E.L EACH ACCIDENT $ SOO�OO OFFICERIMEMBER EXCLUDED9 (Mandrtory In NHJ E L DISEASE-EA EMPLOYEE $ 5��,�� If yes,tlescribe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POIICY LIMIT $ SOO�OO DESCRIPTION OF OPERA110NS 1 LOCATIONS f VEFACLES (Attaeh ACOIm 701,Additional Remarks Schedule,ff more space is requlro� . . CERTIFlCATE HOLDER CANCELLATION YARMOUT SNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEILED BEFORE THE EXPIRATION DATE THEREOF, N0T10E WIIL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health Dept 1146 Route 28 AUl`HDRIZED REPRESENTATNE So Yarmouth, MA 02664 ��.L ,,,.--� {�,G O 198$-2010 ACORD CORPORATION. All rights reserved. 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