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Home My WebLink AboutApplication and WC _ ! ./ . , � F TOWN OF YARMOUTH B4ARD OF HEALTH �� APPLICATION FQR LTCENSE/PERIV�IT-�010 �� 8 ��9 � . �� r�� , . * Please complete form and attach all necessary do�tm ",�� ,c ��r i. Fai�ure to do so witt result in the retum a£y�ur�pp�rcation NAME OP ESTABLISHMENT: r �(/"Z_..r TEL. #�Z�-��=y LOCATION ADDRESS: � MAILING ADDRESS: ��-�,:..� ��11ao1/'r: ' OWNER NAME: /Y11Q�LrA-� /l��-P� �TD (FEIN or SSN1: i CORPORATION NAME (IF APPLICABLE): ' MANAGER'S NAME:_ ��i �'!��-��- TEL. #5� MAILING ADDRESS: sf't9�- � �H-r��u�' POOL CERTIFICATTONS: The paol supervisor mast be certified as a Pool pperator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. r 1. 2. Pool operators must list a minimum of two emp loyees 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 ase past years' records. You must provide new copies and maintain a file at your place of business. �. a. 3. 4. FOOD PROTECTION�VIANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification ta 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. PERSON IN GHARGE: _ . _----- —_ _ - ----- - -- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 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-chokuig procedures below and attach copies of emplayee certificarions to this form. The Health Department will aot use past years' records. You must provide new copies and maintain a file at your place of business. 1, 2. 3. 4. RESTAURANT 5EATING: TOTAL# OFFICE USE ONLY LODGING: LIC�NSE REQUTRED FEE PERMIT# LICENSE REQUIRED FE� PERMIT# LICENSE REQUIRED FEE PERMIT# �BBcB $55 �CA.BIN $55 , _MOTEL $55 .,,_1NN _ _ $55 �_ --- �CAMP : �5 ,:._ . �— <--�_.:� _--_ _ _,_,LODGE $55 ,_„_TRAILERPA,RK $105 „_WHIR.I..POOL $SOea. FOOD SERVICE: LICENS$REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIIt�D FEE PERMIT# 0-100 SEAT3 $85 _CONTINENTAI, $35 ___„NON-PROFIT �30 >100 SEATS $160 �COMMON VTC. $60 WHOLESALE �80 RETAII.SERVICE: —RESID.KITCHEN �80 I.ICENSE REQUiRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE R�QUIRED FEE PE1tMIT# _<50 sq.ft. �50 >25,000 sq.ft. �225 VENDING-FOOD �25 I Q5,000 sq.ft. $80 �� d�03`� _...FROZEN DESSERT $40 I TOBACCO $55 �(a-d.�,Zy NAM�CHANGE: $ts AMOUNT DUE = S 13s.ao ****"PLEASE TURN OVER AND COMPLETE OTHER SID�OF FORM**""* � a ADIVIINISTRATION � Under:Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now requir�to hold issuance or*enewal of atiy license ar permit to operate a business if a persan or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACH�D STATE WURKER'S COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. 4F INSUI�ANCE ATTACHED ` OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�es and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CI�ECK APPROPRIATELY IF PAID: YES� N4 MOTELS AND OTHER IADGING ES'��I�L�SH�A�ENT� _ __ __ TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy, ordxnaril�and customarily associated with motel and hotel use. , Transient accupants must have and be able to demons�rate that they mairnain a principal place ofresidence eLgewhere. 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)manth 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. POOLS POOL OPENING: All swimining,wading and whirlpools which ha.ve been cloaed for the season must be ins by the Health Department prior to opening. Contact the Health Departmerit to schedule the inspection three(� pnor ta operung.PLEASE NOTE:People aze NOT allawed to srt in the pool area until the pool has been inspected and opened. POOL WATER TESTIl�TG: The water must be tested for pseudomonas,total c,oliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSYNG: Every outdoor in ground swimmin$pool must be drained or covered within seven(7}d�ys af closing. FOOD SERVICE 1 CATERING POLICY: i Anyone wha caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Servics Application form 72 hours prior to the catered event. These forms cau be obtained at the ; Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspen�sion or revocation of your Frozen Dessert Pemiit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board afHealth. OUTDOOR COOKING: __ Outdo4r cooking,preparation,or display of any food product by a retail or food seryice establishmerrt is prohibited. _ _ NOTICE:Pemuts run annually from Ianuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN TI�COMPLETED RENEWAL APPLICATIOl�i(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. .ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOI. (i.e., PA�NTING, NEW � EQUIPMENT,ETC.),MUST BE REPORTED T4 AND APPROVED BY 1"HE BOARD OF HEALTH PItIOR � TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ` � /�/ i DATE: ��Z,�S SIGNATURE:__ �'G G��GL-2 C PRINT NAME&TITLE: ,�/��Y�i� /yl,��'��, : � i 09125/09 , ��RTIFtCATE OF L�ABiLITY INSURANCE °�i��`�isio9 Pr�ucer THtS eERTIFf�ATE iS iSSUED AS A MAITER OF A�cia#ion Benef�k�s�gcy tr�c fNFORMATION ONLY ANt�GtN�tFERS IVO RtGHjS UPOiV 7HE 210 Broaciway,Un�201 CERTIFNCATE HOLDER. THtS CERTIFiCATE DOES{VOT Lynr�'reki,MAOt940-1121 AMEIV�,€XTEND OR AITER TH�CElVER�tGE RFFORDEQ B`# THE PQLiG1ES B�L�1t1(. #NSUREitS AFFdRt)ING Gd�RAGE NAiG# lnsured tNSURER A: MA Retaii Merihants WCGroup inc. Gape Wrne 8�Liquor,lnc. IINSIlRER B: 4d3 Station Ave Sou#h Yamaouth,MA d2664 fNSI}RER G: � � }NSURER D: tNSURER E: GE�ifEI�iAGE� 36iE PC3LiC{ES�lNSURANCE US"fE4 Bft HAVE BEEN tSSUEQ TO THE 1NSt1RE0 NAMfO RH01/E FdR Tt�FQLfCY PEl��([�[CAl�O.FI07WfTtfiSTANOit� AtdY REQUIREM€NT TERM�GOIVDfiiON RM`�tdi'RA�'f E)RE)'i'tlER99�kdM@N�iRIFTH��o�-vrT�8-�AIMIGM'tHIS�€16A't�J�IAX$E-iSSUED-Ot�AAAY_ . PLRTAIN iHE{NSURAhICEftFFORL'�D BY . Pf�.iC1ES�SGRtBEOt�REt►J tS SUB.IECfiTU ALl THE TERM3,EXGtU81QNS RNQ CONDITiONS�SUGH POLtCtES. RGGREGA�E LINaTS 5HG1ti9V M1AY tiitYE H� RE�JG'�EC SY PA1D CC;a1MS: _ POUCY �.L � . . . EFP�C7IYE�DATE � PUItCY�Dff'IRRTtON � � - n�R iTit eaGRD TYPE QF tN� POLICY NUM�t OATE U(+MTfi 6Et�tERAL WBILITY �ACH OC:CURRENGE $ .__. _ C�MtM62CfAL GB�iRL LFABN.fTY Flt�OMAA6E{Any an�fus) � CLAIMS MAOE Q OGCUR MEfl E�fP(Any or�pecson} $ � �NRL 3 ADV INJt1RY $ - G�Rt/tGGREGkTE- :$�. GHd'L AGGREGATE LINYT AP?UES P02: PRCM�ICTS—COMPIOP Pd�G $ e PRO- Poucr ,rEcr �� AtiTOM�BtLE LIA&L1iY COhi�t�9NGtE llNNT � _ AN`l AUTO . . �a�n� . . . . .. _ . . ._ _... .. .. .. ._ ... Al.l OYW�D Ai1TOS B(7DILY iNJURY - �$� � SCF�D AUTOS {�P��I FBRED AUTOS BODILY lN.N3RY $ r.aw-awu�auros ��"`�� xoPet�r n�tAn�E $ t(Rer aa�dent) CiARAOfUABiL1TY AUT68t�Y—EAACqDBJT $ ANY AUTO - OT�THAN EA 1�G .� $ � .. AiiTQ Qf$Y ,� g ntcess u,�uitr �;c�+occuR�vcE s occuR ❑ czams nnnoe AccrtEcaTf $ $ oEoucne�e s �rErtx�or� s S vvo�c�s n,�nao � wc srxru- orH- EMPLOYERS LIA�LITY 70RY UMITS ER At�lY P(�P4�Et'ERfPARTNEfLEXCC.lJTtVH EL cACH ACGIf�JT � 1O�J,OQO � OFpC82lME�A�2IXCLU0� Ifyec.descrbeunder �� 014005030752110 1�1H0 11C11111 EL.DISEASE-EAEMPIOYEE � . f0[►.flfl0 SPECIAi PROVISF4NS betwv E�.�xsEasE-PO�.tGYt.tuttr $ 500,040 OTF�R� .... DE9CRlFTiON OF OPERA'ftONS!t6CAT14WS/VB-IICLES/E7CCLUSIdhiS A�D BY E�tDORSEMENT/�%PROVIS9QtJS GERTIFICATE FtOLDER n�non,v_�r�r�m:iNsv�ta�tEr'r�t: CANCELLATION SHC3tN.0 ANY C3F THE ABQYE�SCRtBEQ PQUClES 8£CANCEtLEO BfFORE TOW�of YarRlOUth THE EXPIRA'fiQMDATE THEREOF,THE ISSU}NCINSURERIMLL ENDEAVOR'IY) A7'TN:Lic�rk5ing Off'�s MU�tl�35__DAYS WRtT1'EN NQ�10E To TtiE CERTIFlCATE Ht3Lt3ER tdAMED 1146 Ftotrte 2� TO lHE IEFf,8#1'f FAILURE TO�SOSHALL1hAPOSE NO�i.IGATtENd EN2 South Yarrr�uth,MA 02664 � LIASIUTY�ANY KIND UPON 71-lE INSURER,ITS AGEN75�2 REPRESENTATIVES. . � �.. •lrsunnr+cnnCARaGca►rreTrt.Ic .._. . �..