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Home My WebLink AboutApplication and WC ' BdCK-�S LANi� V 6U,-�6 E '� ► TOWN�F YARMOUTH BOARD OF HEALTH ��(l�'I�� :- � / � APPLICATION FOR LICENSE/PERN�IT-201: � ' ;�, �} � .� {k�� , �� . , �u0 ��3' � �p. . i v. __" * Please complete form and attach all necessary tlooum�nts,,�y 1)�c`e `�r 1 S 2010. �� Failure to do so will result in the return o�y.our�i�ation p c �I�-8 D�, ESTABLISHMENT NAME:�U V11 L 0. � r TAX ID: LOCATION ADDRESS:�I�SI '3Uc� Sc�D �c1 . G��QV dn�� ► ►�1.�� TEL.#:��-�-$-� 13 MAILING ADDRESS:�`�3vc� (S��,cl �d_ W��(�i,►�vYt,6W4�, , ��r. 0�(,�'� OWNER NAME: CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#:. MAILING ADDRESS: FOOL CERTffICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State la�v. Please list the designated Pool Qperator(s) and.att��h a co�X o�the certificatioii ro this form. 1. 2, Pool operators must list a minimum of two employees cun•ently certified in basic water safety, standard Fu st Aid aud 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 Gle at your place of business. 1. 2. 3. 4. FUUD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are required to have at least one fiill-time employee who is certified as a Faod Protection Manager, as defined in the State Sanitary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department ti�vill not use past,years' records. You must provide new copies and maintain a file at your establishment. L 2. PERSON IN CHARGE: �.ach food estab�islunent must have at Ieast one Person In Charge (PIC) on site duruig hours of operation. 1. 2, HEIMLICH CERTffICATIONS: All food seivi�e establishments witn 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all times. Please list your em�loyees trauied in anti-choking procedures below and attach copies of employee certifications to this foi7n. The Health Department will not use past years' records. You must provide ne�v copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGL\G: LICENSE REQLTIRED FEE PERi�IIT� LICENSE REQUIRED FEE PER'VIIT� LICENSE REQUIRED FEE PERMIT� _B&B S�5 _CABIN S5� MOTEL S» _._--INN S55 —_—_---- —CAMP S55 _.____—_ ?,S�VI,'�I,NIINGPOOL 580ea. _�b Z8 _LODGE S5� �TREIILERPARK S105 �VFiIRLPOOL S80ea. FOOD SER�'ICE: LICENSE REQUIRED FEE PERl�IIT� LICENSE REQL�IRED FEE PERVIIT= LICENSE REQUIRED FEE PERi�ZIT� _0-100 SEATS S85 _CONTINENTAL S35 NON-PROFIT S30 _>100 SEATS S160 _COMMON VIC. S60 ��IOLESALE S80 RET�II.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER'�IIT� LICENSE REQUIRED FEE PER�IIT.~ LICENSE REQUIRED FEE PERIVIIT# _<50 sq.t3. S50 _>25,000 sq.ft. S225 VENDING-FOOD S�5 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S» \AVIE CHA\GE: sis AMOUNT DUE _ � (60.00 ***"�PLE:�SE TLRti Q�'ER A�D CO�iPLE�'E�THER SIDE OF FQR�4***** ADMINISTRATION . '�, Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewai 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 MUST 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 prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO IVIOTELS Ai�VD OTHL�LODGIlV�G�ST�I3LISHMENT'S TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy sha11 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 ofresidence 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. - --- --- — --------__ __ _�QUI.S__ _ ------ ------ ----- — 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 mspected 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. � Pt)�J►�"i.Cpi.US1I�G: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 ins�ected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3) days prior to operung. , 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: Outside cafes(i,e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. I 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 RESPONSIBILTTY TO RETLJRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY,�2EC�,UIRE ArS��-�g�.�T. l � DATE: 1 � � SIGNATURE�� , �� PRINT NAME&TITLE: �� ,��,� j (��,�fti�rv�.�,�}�'/�1-S�G� � 10�06�10 • �r"', '4�fRo�� CERTIFICATE QF LIABILITY INSURANCE °ATE,MM'°°"r", TNS CFRTIFICATE IS ISSU� AS A MATTER OF INFOPoNATION ONLY AND CdNFERS NO RIGHTS UPON THE CFRTIPICATE HOLDBt. THIS C92TIFICATE DOES NOT AFFIRAAATIVFIY OR N�'aATIVaY AMBdD, IXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIC165 B9.OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A GONTRACT BEfW�i THE ISSUING INSURER�S), AUTHOPoZ� REPR65ENTATIVE OR PRODUCE AND THE C9tTIFlCATE HOLDER. . e cer ic e o er s an e po cy es mus e en orse . su e o the terms and conditions of the policy,certaln policies mayrequire an endorsement. A statemerrt on this certiflcate does not confer rights to the PRODUCER 781-247-7800� . odman Insurance Agency,Inc. 7g1-444-0090 �ONE 45 RosemarySt.,Bldg.A e•�aa� eedham,MA02494�238 Pao�uceR .gUCKI-2 e ffre y G rosse r INSUR62 S pFFORDING COVERAGE NAIC i INSURED Buck Island Village Condo iNsuR�xn:A.I.M.Mutual Insurance Co. clo Office _ in�zeRs: __.___ _ _ - —__ _ — _ 481 Bucklsland Rd INSUR62C: W Yarmouth,MA02673 INSYlRHt D: � � IN3URERE: HIS I O CERTIF HAT T E POLIC ES OF I ANCE LI BELOW AVE BEEN I UED TOTH I SURED ED ABO R THE CY PE I INDICATED. NOTWITHSTANDMIG 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N� � POUCY EFF POLICY EXP GENERAL LIABILITY EACH OCCURRENCE $ -�COMMERCIAL GENERAL LIABILITV � � �$ �CLAIMSMADE a OCCUR � . MEDEJ4�(Arryoneperson) $ PERSONAL&ADVINJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: . � PRODUCTS-COMPIOPAGG $ PR4 $ AUTOMOBILELIABILITY COMBINEDSINGLELIMIT $ ANY AUTO (Ea acciden[) BODILYINJURY{Perpersm) $ � � ALLOWNED AUTOS � BODILY INJURY(Per accident) $ � � SCHEDULm AUTOS � PROPERTY DAMAGE $ - HIRED AUTOS (Per accident) � N ON-O�MV ED AUT OS $ $ UMBR�LALIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMSMADE AGGREGATE $ DEDUCTI�E $ W ORK92S COMPENSATION AN�EMPLOYERS'UABILITY Y!N X A ANYPROPRIETOR�PARTNERfEXECUTNE ❑ w(Cs��Qs$rj��2�� 11108l10 11108/11 E.LEACHACCIDENT $ J�� OFFlCERIMEMBER EXCLUDED? N!A � (M�dffioryin NH) EL DISEASE�-EA EMPLOYEE $ SOO,O If yes,desaibe under � 5 DESCRIPl10N OF OP92ATIONS t IOCATIONS!VEHICLES (Attaeh ACORD 101,Rddition�Remarks Schedule, if more spaee is requircd) YARMOUT SHOULDANYOF 1HE ABOVE DESCRIBEDPOLICIES BE CANCELLEDBEFORE 7HE El(PIRATION DATE THEREOF, N0710E WILL BE DELIVERm IN Tow n of Ya rm outh ACCORDANCE WI7H 7HE POLICY PROVISIONS. Board of Health Dept 'I'I4B ROUtC ZS AU7HORIZEDREPRESENTATIVE So Yarm outh,MA 02664 �� { O 7988-2009 ACOR CO O IOPI. II rig ts reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD