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Home My WebLink AboutApplication and WCop TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/P TMAY 1601 a.. o * Please complete form and attach all necessi c ents' by,.De' m T. Failure to do so will result in the return of your application pac - - -- ESTABLISHMENT NAME: It PA -4--K TAX ID:� LOCATION ADDRESS: > 2 M R,-Af g4— TEL.#: 5"ok -7';,) -ala! MAILING ADDRESS: SIN -„-e- L=NnILs VL(WeQ R►k� G� OWNER NAME: ,S j,". b A)"— 140 l C1 CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: 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. P 1 tt, 2. Pool operators must list a minimum of two employees 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 use past years' records. You must provide new copies and maintain a file at your place of business. 1 3 FOOD PROTECT. All food service e: Protection Manage Please attach copie ^rl� You must provide 1. PERSON IN CHAI Each food establish 1 2. 4. .ie full-time employee who is certified as a Food ,00d Service Establishments, 105 CMR 590.000. Ith Department will not use past years' records. ublishment. e (PIC) on site during hours of operation. HEIMLICH CERT] All food service esi !�, �`ic e-..t-� — �" e at least one employee trained in. the Heimlich Maneuver on the pr Aj,,y Ar,,, �" 4 -pp (� !es trained in anti -choking procedures below and attach copies of emp... ,� ..,� Liiiva L)11N Lu Lms rorm. 'I'lie Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1 3 RESTAURANT SEATING: TOTAL # Q OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # _B&B $55 _INN $55 _LODGE $55 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # _0-100 SEATS $85 >100 SEATS $160 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # _<50 sq.ft. $50 _<25,000 sq.ft. $80 NAME CHANGE: $15 LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _CABIN $55 _MOTEL $55 _CAMP $55 Z SWIMMING POOL $80ea._ -d� _TRAILER PARK $105 WHIRLPOOL $80ea. 't i 7i-- 03A LICENSE REQUIRED FEE PERMIT # _CONTINENTAL $35 COMMON VIC. $60 LICENSE REQUIRED FEE PERMIT # >25,000 sq.ft. $225 —FROZEN DESSERT $40 LICENSE REQUIRED FEE PERMIT # NON-PROFIT $30 _WHOLESALE $80 —RESID. KITCHEN $80 LICENSE REQUIRED FEE PERMIT # VENDING -FOOD $25 TOBACCO $95 AMOUNT DUE = $ 215--O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION 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 Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION 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 APPROPRIATELY IF PAID: YES ✓� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: 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, shall 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 Department to schedule the inspection three (3) days prior to opening. PLEASE NOTE: People are 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 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 of Health. 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT MAY =SITE PLAN. DATE: �J) fes` / 3 SIGNATURE: PRINT NAME & TITLE:�� Rev. 10/09/12 I �'�� CE�TtFICAT� �F LIABILITY INSURANCE °"�`�"'°°"""' � 5/22/�3 THS CER11FtCQ`iE IS ISSUED AS A MATTER�F II1�OIiMAT10N OF�.Y AND CQNFERS NO R[GFkTB UPON THE{��Ri'i�lCATE HOLDER. TWS CERTIFlCATE t�E$ Nt)T AfFIRMA7NELY OR NEGATINEI.Y AMEt�, E�IEI�? GR ALTEF�TI� COVERAGE AFFORt�D eY THE POLICIEB ; BELOW. TFtlS C�RTIFlCATE OF INSl1RJ�10E DOES ND'�COPlSTffUiE A CONTRACT B�TW�EN THE ISSUING EtdS1�R�Fi{S},AUiHOi21ZED i REPi2�S�NTATiVE pR PR��iJGER,ANQ Tf-lE CEfiTtFICA'F'�HOLDER, IM : the ce�lificabe holder Is an ADDIi'tONAI.1 URED,ihe policy(ies)rr�at be endarsed. {f SUBROGA7i N IS WNvED,$abJect to the temts aRd C4nt6tiolts ofthe polisy,certai�policies�y require an endorsement A sta�ment on this certificate dces no!conter righls b the certificate holder in�iau of such endorsement(s}. �owc� nx�: Linda Hake�r Choiae Insuzanee Agericy� Ix1a. 978 343-4853 y°' N - ig7Q) 3�9-i007 376 8t+mp►er 19treet lbaker@ahviae-insurance.com. a-eoo-6as-a853 IN$UI� 8 AFFOR�ING CDVERAGE NAiCS I E'itehburg, MA 01420 i��A:�p,,��Q� g �xeial Ins Co 1t'$�� INBURER B: Sandbar Msnagement IAC �n�suRe�ec:Civard Insuranae Grou � d3�a Cap� Cod Infl.atable Park ��RBtD: P.O. 8px 48], � a��: Wes�t Yarmouth� MA O2�I3 IWSURFRF: i COYERAGE3 CERTIFIGATE NURABER: REVI5lON NUAABER: THIS IS TO CERTIFY IW�T THE PQLICES flF 1NsuRANCE USTED B0.0W HAVE BEEENEE ISSUED TO THE INSURED NAM�ABOV�FOR THE POLICY PERIOD WDICAT�. NCITMTI'lSTANDAVG ANY REQU113EMENT,TERM OR CQNDITIQN QF qNY CONTRACT OR O7HER DOCUMENT WffH RESPECT TO W�-��CH THIS I CLRT�ICATE MAY BE ISSUED OR MAY PERTAIN,TN�INSURANGE RFFpRDED BY TI-E P�.ICIES DESCRIBED MEREMI IS SUB.IECT TO All ll-!E T�RMS, I E70CLu$IQW.S AND C�NqTIONS OF SUC�i POl1CIES.LIMP'fS SHpWN MqY NAV�B��PI REDUCED 8`(PAID CLAIM9. , . t-� 'rrPEOFtNsuRrwCE aoo su roucv aue�� M roaYrrY u�ts A �+��0m' PROOQ60819 5/20/13 5/20/14 �HOCCuwtENCE s 2 OQO d00 ' X GONMERCtALGFNEPALLfAB1uTY RENTE6 $ 100 000 CLAIIU�J�AAOE a OCGUR MED E7U�W�H a�e perom i � pERS01�WL�ADVtK1URY s 0 000 � GENERALAGGREGAFE S OOQ OOO CiEN'LAGGRE6A7ELMTARPLIESPER Q��1�g-��P� = Z OOO OOQ POLICY PRO• �� 3 R AUTONO&LE LWBRJ7Y e accidant AMYAUTO BOD�YlNJUkY�arpewon) $ ', ALLOWI�ED SCHEDULED B000.YINJURY{Petsc�adenq S � PROPER{Y AlJ1'6S NON-�ONMED aa S HIREDALffQS _p1JTQS ; v�ygJ�LLqLJpg Op�� ERCHOCCUF3tENCE S E!(CF�B LtA6 CLAIMs�fYlOE AJGGi�G0.'rE 3 OED RETENilo7d g g C ��G��'� SAt�C355975 5114/13 5/14/16 ��AT� g �"- nr�a euatov�tts�uaewrv '��I�P�� Y� N1A E.L.EACHA�CQ�ENr �. OOO OOO OFF�k�AAEN6Ht EXG.WEDT EL.Q13EA3E-EA 9JFLdYE �. OOO OOO pAa�Walpry In NH� ; rcyee ae�ioauncer �,L.OISERBE-POLfCYLIMR' 1 Q0� 000 dfiS4�RIPTtON OF OP�PATfON5 below aESCRIPTON QF QP6RATION81 LOCA710I4S 1 VEfICL65 (Atmch ACORD 701�Atlmgonal RemaAm$cnetluk,if�tore sp4ca b mqu�d} Operatibna o� Insured FAX� 508-398-3184 C�TIFICATE HQIDER CANC�LLATION SHOULD ANY OF lHE A80VE DESCRIBEO POIJCIES BE CANCELLED BEFC?RE Tti� �XpIRA710h DAYE TH�I�OF, NOTtCE W!LL �� bEl1VERED �1 TCwn Of Yarmauth ACCOftbAlJC�WItH tH�POLICY pROV131bN9- j Route 28 Yarmouth, MA 02664 auTM��rn-rn� Linda Baker j �1988 201Q ACORD GORPORATION. All right&resenred� I, ACORD 25(201010� The ACORD name and logo are registered marks of ACOFtb 1 piton�: {978) 343-4853 �� {9781 345-1007 E-Mail: lbaker@choiee-insursnce.com i