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Home My WebLink AboutApplication and WC ._�� '� TOWN OF YARMOUTH BOARD OF HEAL .;��°- APPLICATION FUR LICENSE/PE � �, - Iisv .I�T� 2� ` '�, . za�--�,, - �� - NOV 1 7 r ��g * Please complete form and attach all necessary dQ��. . ` ��,ecef utr i. Failure to do so will result in the retum o��au�a�i�cation pa �TAME OF ESTA�LISHMENT: UC,I� �H`n� _ Vr (.LPr� (�,Q�!l�0 TEL. # S.U� �`�"S�(�513 LOCATION ADDRESS: �� UC, S 'D 1Z � T ��iN� �?,1.�-3 MAII.ING ADDRESS: �l g( u l D �2d• 4s� �cl�i,�`E-i � !^�� 0��.� OWNER NAME:��c.t.c- S ' NiJD � � T D FE r S � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. # MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiapulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certificatians to this form. The Health Department will not use p�st years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION�v1ANAGERS - CERTIFICATIONS: All faod service establishments are required to have at least one full-time employee who is certified as a Food Protection Mana�er, as defin�d in the State Sanitary Code for Food Service Establishments, 145 CMR 590.000. Please attach copies af certification to this application. The Health Department will nat use past years'records. You must provide new copies and maintain a file at your establishment. 1. - 2. PERSON IN CHARGE: �ach good estabt�shment must have at Ieast one Perso�n In Charge(PIC) on site during hours of operation. 1. 2. HEIMLICH CERTIFICATI4NS: All food service establishments with 25 sQats or more must have at least one employee trained in the Heimlich Maneuver on the prernises at all times. Please list your employees trained in anti-chQking procedures below and attach copies of employee certifications to this form. The Health Dep artment will aot use past years' records. You mast provide new copies and maintain a file �t your place of basiness. 1. 2, 3, 4. RESTAURANT SEATING: TOTAL# OFF�CE USE ONLY LODGING: LIC�NSE REQTJIRED FEE PERMIT# LICENSE REQUIRED FE$ PEKMtT# LJCENSE REQUIRED FEE PERMIT# � _,_,_B&B $55 CABIN $55 �MOTEL $55 2NN $55 �Ct�1F $55 2 SW�LL'�I�iG POOL �80ea. #�� LODGE $55 �'TR,AILERPARK $105 ,�WI3IRLPOOL $80ea. FOOD SERVICE: LICENS�REQUIRED FEE PERMIT# LICENSE REQUIRED f�E PERMIT# LICENSE REQtJIIZED FEE PERMIT# �0-100 SEATS $85 _CONTINENTAI, $35 NON-PROFIT $30 :- :>100 SEATS $160 �COMMON VIC. $60 �WHOLESAL£ $80 RETAIL SERVICE: �RESID._KITCHEN �80 LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC�NSE REQUIRED FEE PERMIT# i �<50 sq.R. ' $50 >25,000 sq.8. $225 ____VENDING-FOOD $25 <25,000 sq.ft. $80 ,_._FROZEN DESSERT �40 TOBACCO $55 NAME CHANGE: s i s AMOUNT DUE = S !�p.o 0 "**""�'L�ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** r ..,.,. _ .,., ,.. .a .. , �tr , �. ADMINISTRATION , , , , . Und�r•��G�agter 1�2;;Section ZSC, Subsection b,the Town of Yazmouth is now required to hold issuance or renewal of a.ny license or pernut to operate a business if a person or company does not have a Certificaxe of Worker's Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATIUN INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE 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 APPROPR�ATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISIIMENTS . TRANSIENT OCCUPANCY: For purposes of the limitations of Matel 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 ofresidence eLs�where. Transient occupancy sha11 generally refer to continuous occupancy of not more than t�rty (30) days, and an aggregate of not more than ninety(90) days within any s�(6)month period. Use of a guest unit as a residence or dwelling unit sha11 nat 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: R � _ . ._ ____.....____... f POOLS POUL OPENING:All swimming,wading and vvhirlpools which have been closed for the season must be inspectecl by the Health Department�prior to opening. Contact the Health Departmetrt to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the poal area until the pool has been inspecte�l and apened. _ POOL WATER TESTING: The water must be tested for pseudomanas,tatal cnliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to apenin,g, and quarterly thereafter. � ; POOL CLOSYNG: Every ontdoor in ground swimmin�pool must be drained or covered within seven(7)days of closing. i FOOD SERVICE � CATERING FOLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Applicaxion farm 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DE5SERTS: Frozen desserts must be tested on a monthly basis by a State certified Iab. Test results must be sent to the Health Department. Failure ta do so will result in the suspension or revocation of your Frozen Dessert Permit untit the above terms nave been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: � 4utdoor cookin�_Qre�aratio�Qr is l�y o_f an�food�Qd�ct b�_�r�tvl�r fo9��rvice establi��t��rohilt�ted,__ � NOTICE:Pertnits run annually from January 1 to December 31. IT IS YOUR RE�PONSIBII.ITY TO RETURN TI�COMPLETED RENEWAL t1PPLICATION(S)AND kEQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TQ ANY F40D ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENC4VATIONS MAY REQUIRE A SITE PLAN. ° ; - i � DATE: SIGNATURE: ' PRINT NAME&TITLE: I�� 09l25/09 �-�--�« �om:S. Hale FaxID:781-444-�090 Rodman Date: ii/4/2009 11 :53 AM Page: 2 of 2 ACORD. CERTIFICATE 4F LIABILITY INSURANCE OPID SH DATE(MNWDIYWY) PRODUCER BUCKI-2 11/04/09 ONLY AND CONFERS NG RIGHTS UPON THE CERTIFICATE Rodman Insurance Aqency, �nc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 145 Rosemary st. , Bidq. A ALTER THE CC�VERAGE AFFORDED BY THE POLICIES BELO Needham MA 02494-3238 Phone: 781-247-7800 E'ax:781-444-0090 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Arb�lla Protection Insurance B ek Island Village Gondo �NSURER B: Cllll}�b t�rOLliJ C O Office INSURER C: 4�1 Buck Island Rd INSURERD: W Yarmouth MA 02673 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PERIOD INdICATED.NOTWITHSTANDING MV PFRTAIN THFTIN.SI RON F 4OFFD'R FIJ1 RV THF POI 1(`.�FS�1FO4 R RFf!HFRF`IN C�SI R!IF T T(�PGIGI THF�RM.ShFXri ER��FNGA�TE�MAnNnITinNGED OR�rH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L7R NSR TYPE OF INSURANCE POLICY NUMBER DATE(MNUDDIYY) DATE(MM/OD/YY) LIMITS GENERAL�IABIL�iY EACH OCCURRENCE $ 1�OO��OOO a�i }{ COMMERCIALGENERALUABILITY 8500041883 O1/O1/U9 01�0�.��0 PREMISES(Eaoccurence) $ rJ��O CLAIMS MADE a occuR Meo��r,y o�a par�or,� � 5,000 PERSONAL&ADV INJURY $1�OOU�OOO GENERAL AGGREGATE $Q�O D O�O O O GEN'L AG�REGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG $ 1�OOO�OOO POLICY �Ea LOC � AUTOMOBq.E LIABILITY COMBINED SINGLE LIMIT ANY AUTO $ (Ea acciderd) ALL OWNED AUTOS SCHEDULEO AUTOS BODILYINJURY $ (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AIJTOS (Per accider�t) $ PROPERTY DAMAGE (Per acciderd) $ GARAGE LU181LfTY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN �`�� $ AUTO ONLY: AGG $ EXCE33NMBRELLALIABILRY EACHOCCURRENCE $ 1SO�OOOO B X OCCUR �CLAIMSMADE 79870�53 ��.�UZ�O9 OZ�O��.O AGGREGATE $ ZSUOOUOO $ DEDUCTIBLE X R�nrrION S lO,OOO $ S WORKERS COMPEN3AT10N AND EMPLOYERS'LIABILfTY TORY LIMITS ER ANY PROPRIETOR/PARINER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED9 If yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below 07HER E.L.DISEASE-POLICY LIMIT $ A Property 8ection 8500041883 01/U1/09 O1/01/10 RC/SPEC $17,5�2,209 � IN 117 UNITS AA 510000 Ded DE8CRIPT1pN OF OPERA710NS!LOCATIONS!VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECUIL PROVISIONS $10,000 Wind Ded; Water Backup $50,00o w/$1�0�0 Ded Fidelity $200,000 w/$1U00 Ded; Directors & Officers $2,0�0,000 Boiler & Machinery incl in property 481 Buck Islaad Rd, W Yarmouth MA 02673 CER IFICATE HOLDER CANCELLATION B�K__ SHOVLD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER YNILL ENDEAVOR TO MAIL 1� DAYS WRfTTEN 'k***'k'�''k*SAMPIaE'�'�'***�'�'**'k* NOTICE TO THE CERTIFICATE HOI.DER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL #'*#'rl'�k+k*1F**rF*4*9F�k�k�k�k tk****.�,***�.* IMPOSE NO OBLIGATION OR LUIBILRY OF ANY KIND UPON THE IN3URER,�TS AGENTS OR *****rF*ik**r4**#�************rF**tF REPRESENTATIVES. *Ylr*9F*lktlr*rk**4F1tyF**�k****rFil�tkyFtlP*rF*Yt A