HomeMy WebLinkAboutApplication and WC ` f. G�I�C�(���IG�CD � �� ,
, � � TOWN OF YARMOUTH BOARD OF HE TH ,�f S���J�
` � � APPLICATION FOR LICE�I,SE �: -20�'�r'� �� ���� ����w,,����
:...,� ,�
* Please complete form and attac�� s nt� ��rKD'�� 011. $� �,�,� �
Failure to do so will result;in t�:r' your ion pac et.
' �c ���,. �a t�( Ta�ID: '�-
ESTABLISHMENT NAME: �2�L
LOCATION ADDRESS: S�2 .� 22�" l.���i��a��'``- TEL.#: So� �7 /—�lo�
MAILING ADDRESS: S�ivL
OWNER NAME: ,1 cz-,"��4..i�ih�-r„z l-�� I dc��
I CORPORATION NAME(IF APPLIC BLE): �` �- 4,1� . �� � �"
j MANAGER'S NAME: •��J°K� � ��� TE .#: o� 3Cl Y �
j MAII.ING ADDRESS:
� POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. P �����'i��
Pool Operator(s) and attach a copy of the certification to this form.
�. .�y I v:� r►���n.c 2.
��� '� � �012
, HEALTH DEP1.
Pool operators must list a minimum of two employees currently certified in basic water sa
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�le at your place of business.
� l. �'t� `��� /��� 2, '� �/n.�
��� s
3. 4.
FOOD PROTECTION MANAGER5 - CER'TIFICATIONS:
; All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
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�le at your establishment.
1. 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation.
l. 2.
HEIlVII.ICH 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-choking procedures 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. �;b l�� i2-� 1&�-.� 2. -Su 1 ��-. r��
I 3. 4.
�
' RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 / MO'TEL $55 �l2'OSI
/Z•�g
_INN $55 _CAMP $55 Z SWIMMING POOL $80ea.�/Z'Q,9�
_LODGE $55 _TRAtLERPARK $105 � WHIRLPOOL �8oea. #�Z�3``
FOOD SERVICE:
-- -- --___-._`_ _ _ _ -_-
--- - -— ------ ---- - _
LICENSE REQUIREll FEE PERMIT# LICENSE KEQUIRED FEE PERMIT# LICENSE P�sQUiREI? FF.E PERl�tIT#
_0-1005EATiS $85 _CONTINENTAL $35 _NON-PROFIT $30
� � > 6�8�,7�'1' $160 � M0�1 VIC. $60 _WHOLESALE $80
! RETAII,S�R CE: �� —RESID.KITCHEN $80
� 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 CH�NGE: $15 AMOUNT DLTE _ $ �� -- ��
***�*PLEASE TUIt1V OVER AND COMPLETE OTHER SIDE OF FORM• a�� '
�x***�
1
__ _�..�_ - - �
- �
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 �
I
�
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 ESTABLISHIVIENTS f
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 cansidered 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 OPEIVING: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 �
prior to opening.PLEASE NOTE:People are NOT allowed to sit m 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 OPEI�IING:
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 i
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 f
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 CAF�S: '
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 prohi6ited.
---- -__a___ i
._---- -_____ _ _
__ �_ _--,_ _____ ____� �
�
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RE5PONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIl2ED FEE(S)BY DECEMBER 15, 2011.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQiJIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i
TO COMMENCEMENT. RENOVATIONS MAY E A SITE PLAN. '
!
DATE: ��r Z�j�� SIGNATURE:
PRINT NAME&TITLE: �D �� �� ��=�
Rev.;0/25/11
�
i
j
co� CERTIFtCATE OF LfAB�LtTY INSURANCE °�'�""�°°"'""'
3312
THS CERi1FlCi4'TE IS�AE A MATIHt O�MFOI�MA7ION OIi.Y Al�OON�NO�K(8 11PON 7!�CERRIFICATE 11QLDER 'fH8
',' CER7FtCATE DOES NQT Af�IA'iiVEIY OR f�tiATI11ELY AM�D. EX7E1�OR AL7ER TFE CWERA�tiE�IFFCROED B1f TtE POUCIE3
BELOYY. TH8 CERTIHCJITE OF��AN�flOEB NDT 001�1TtlIE A CON7RAiCT BETYYEEN TFiE �l�Nti �U�1�Al�l"FIO�IZED
�EM'A7NE OR PAODtJ�R.At�'iF1E t�PIRCA'1f
��and oa��o�s ottlN P�I��1 n�ust b�w� A subj�ct eo
P��P��f►nQir�'�tndor�enNnt A�n�nt oa Ws pAMioab doos nd ea�r ei�fb bD fio
�hold�r h Ma af wch
e�odx�e
Choice Iasuranve Aqsa�cy, Is�. . (978) 8�5-1007
37s 9vauriar Str�t choi choica-iasuraace.ao�
I P'itchb�uz^g, l�a 01420
w�s
1 A: iWC�
�� � j
' P+a3.sa�aoa Pi�zs, Iae. : �.
450 I.ancast.�r Stra�t �
Iso�i.nat�r, 1rDl 01453
COVERA(,ES �FCATE Nt�IBEI� REVISION Nt�ER:
7HlS IS'fa I�iTIFY TFWT 7HE Pa.ICE3 QF INSURANCE U91'ED SB.AN W1YE B�!IS9lJED TO THE wSt�ED NM��ABQVE FOR Ti�E.P�Ot.ICY PB210D
qdDICAT�. NQTiIVITHSTl�1�NCi AIVY El�Qll�tl'.lE�IIA DR QONDIT1f��1 aF AHY CONTRACT dt Ql'F�2 DOCl1�1T V1fITli RBGPECT TO IIVF�Nqi THIS
CERTFICATE MAY BE ISSU�OR MAY PERTAN.THE AVSIIAiANCE AF�BY TtE POLI�S D�IBEU HHtEN IS StlBJBCT TO ALL TFI�TERMS.
�OCLU90NS ANDCflN�R101d8 OF SUQi POUCIES.LM17'S�NMY FNVE�B�t�BY PM Ci�4M8.
YVPEORtt�utAru� uns
g aeHee,�waertmr RC8102�31 9/2/is sl2Jx2 Eac►+occua�c£ s
co�ra�uc;�rEw►�u�eurr ��,�,�o,
CUMs� �oaCUR ir1EDE7P r«r .aay s 0
i {+9iS0lMLilID'YINILIRY i
, . (�RI11.ALi(iREG�t1E f
CiBI'L#flOit�A7ELMTAPPLE8PER PROOt1Cr8-UQirPI0P/1t�(a i
1
POLICY LOC =
I II4►TOIIOBIL,fi LIIIHIYYY ��
M1YAt1W _ BOOILY p1�RJRY(Po►P�aon� i
PLLOMN'E� � . 60DK.Y6�LMJRY(Praoddr�q i
N770S
HIREDAUi06 _� _ r � i
;
i
i � OMIELLAUA6 OaG1R FACHOCCUIRENCE 3
I �� CLAMR8IMl10E AiOQREQATE f
1
� A vrae�et caw�uwM TNC33�:4695 slsi/i2 5/2sl13 g wc sr�Tu-
( N+nern.arf�u+�uir �
� ����nue Y� �� 100�0„00
N�+�,+o�rp,x�+} —J I00 000
p ua.r
E LMR OO
S Liquor Liarbility R�CB102031 g�2�x1 g��»1,000,000 1,000,400
� "
ae�a�ovevmoNs�wanoNs rvs�txs Ir�r�u�nr�o�n,Ar�aW aw.ns se�waw..wwoe..�.sw��
p8R11TI�8 OF ZNStJ1�D
I
I
� '
i
j C6tTIF�ATE HOLDER CANCELLATION
s�utA nNr oF��►aovE c�scsise�na.�cEs aE crwe�.�c a�onE
tee dcrianap or►�e rHe�eoF, � wwnaa. � oEuv�o N
�okn of Yasaouth AacoKc�wcawrr►i 1l+E aa.�cY�au�Dt�s.
� Rt 28
� Yaza�outh, AA 02654 ����
� Fet�r C. DiPa
o t�a�o � �n rq nserrea.
� AOORD Z6(ZM OiIDS► TM/IC�tD nnr and la�o aro e�rtd rearb ofi ACQRD
PFqne: {978) 3�3-4853 F�c: (978) 34S-10i07 E�: p�t�rAahaiaQ-inauraaoa.c�
i .
i
MAY. 24. 2012 2;42PM HART INSURANCE N0. 099 P, 1
A�� CERTIF�CATE OF LIABILITY INS�IRANGE °A 5��T'Yz'
THIS CERTIFIGATE IS lSSUED AS A MATTER OF INFORMAl10N ONLY AND CONFERS NO RIGHTS UPON THE CEF2TIFlCATE HOLDER. THIS
CERTIFlCA7E DOFS N07 AFFIRMA7IVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER TH� COVERAG� AFFORDED BY THE P0IJCIES
gELOW. THIS CER7IFICATE OF INSURANCE DOES NOT CONSTITU7E A CONTRACT BETW�EN THE ISSUING 1NSURER(S), AU7HORIZED
REPRES�N7ATIVE QR PRODUCER,ANU THE CER7IFICATE HOLDER.
IMPOR7ANT: ]f the Cart;f[cabe ho�der Is an ApDIT10NAL 1NSURED,the policy(ies)must be endOraad. If SUBROGATION 13 WAIVED,subjcct to
the terms and conditions of the policy,certdin policieg may requira an endorsement A statsm9nt on this cartificate does not confer Hghts to tl�
cArtificate holdar in lieu of sueh�ndorsamsnt(s).
PRODUCER ,u,E_ T Laura J Murphy
NAR7 INSURANCE AGENCY,INC, pHows , (508)759-7326 Fy N„508-759-7366
243 MAIN STREET E.Mn�
PO BOX 7O0 aaDR •
BUZZARDS BAY,MA OZ53ZO7_,QQ,,.:_..�-a.�,�....-.P,,.�,.;�-„�.-��=a, INSUR� S AFFORD�N6 COVERAGE NA��
L.---- _ � asut�a: ARB�ILA SPECIALIY INS b0009
IN3URED Irish Vll�ge Holdings,Ina Ef wsu�zs:
822 Route 28 M V 2!; i��� ' � u�sur�c_
South Yarmouth,MA 02664 � ' !�{� v
� qJSUREIt D:
B
����:i�r_�8�s `�"�:E'�. � INSURERE:
WSURFR F•
COV�RAGES C�RTIFlCATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 7HE PO��CIES OF 1NSURANCE LIS7ED BElOW HAVE BEEN ISSVED TO THE INSURED NAMED ABOVE FOR TIiE POLICY PERIOA
1NDICAT�D. NOTWITNSTANOING ANY REQUIMtEME�1T,TERM OR CON�ITION OF ANY CONTRAC7 OR OTHER DOCUMENT 1MTti RESPECT TO Wh11CH THIS
CER7I��CATE MAY BE ISSUED OR MP.Y PER7A�N,THE INSURANCE AFFORDED BY THE POLICIES DESCRI6�p HERE�N IS SU6JECT TO ALL TFIE 7ERMS,
EXCLUSIONS AND CONDffIONS OF SUCH PO��CIES.LIM17S SHOwP1 MAY NAVE BEEN REDUCEO BY PA1D CLAIMS.
�N� POLICY EFF PO�JGY E7(P ���
'IYPE OF INSURANCE 5 gR POLJCY NVMBER MM/D MM/D
G�wE�uaenin �c►ioCCURRENCE s
CqMMERCIAL GEN�RAL LIA81LfTY PR�MI D n S
CLAIMS-0AADE �OCCUR MED EXP A one eraon) S
PERsoru�a Aov iN�uaY s
GENEW�AGGREGATE S
�
GEN'I.AGGREGATE LIMIT APPI�ES�R: PRODUCTS•COMP/OP AGG S
POLICY PRa LOC s
AUTOMOBILE LL461L.fTr CO aBINED IN MIT
BODILY INJUR�(Por persun) S
wNY AUiO
aLL OWnfED SCi1EDULED BODILY INJURY(Per ealqenl) E
AUTOS NON�OWNED PROPERTY DAMACiE $
M(R@DAUTO$ AU'r0S P racdde
5
UbIBRELLALfAB OCCUR EACFIOCCURRENCE S
EXCESS� C�IMS-MADE AGGRE(iATE S
DED RETENTION S S
A WpRK�$COMPFs13AT10N 9099540611 06/13/2011 06/13/2012 'h'�Srnzu- o'rH-
AND EMPI.OYEixS'LIABILITY
nNYPROGRIETORlP�7NEWIXECUTIVE r�N 06H3/2012 a6/13/2013 E,L.�Ap�lACCIDENT 5 5���0�
OFFlCER/MFJ��ER D(CLUDED7
N ro r n 5.00000
(Mandatory In NH) E,L DISEASE-EA EMPLOYEE S
�r Yo�das°'b°u'dd� EL DISEABE-POLICY LIM�T S SO0000
OESGR�PTI N OF OPERATION$Celow
oESGRIPTION OF OPER/4710N5/LO�A710�1YP_MICLES(Atdth ACORG to7,pddhlonal Ramatl�e SehedAN,H rtwn�paco la nqulred)
Opetations as perFormed by Terms 8�Conditions in the pOliCy-Motel 8 Restaurant F�cposur�
822 Route 28,South Yarmouth,Ma_
CERTIFICA7E NOLDER CANCELLATION
TOWN OF YARMOUTH
HEALTH INSPECTOR SNOULb ANY OF TH6 ABOVE DESCRIB�D POLICIES BE CANCELLEO BEFORE
'1146 MAIN STREET 71iE EXPIRA�ION DA,TE 7HEREOF, I�T�CE wILL BE DELIYERED IN
S YARMOUTH,MA 02673 ACCOR�ANC�W1TH THE POLICY PROVI310N3,
Faxed 506-398-0836
i
AUTHORQEO R�PR�S�TA7fVL
m 1988-2010 ACO . AIf rights reserved.
ACORD 25(209 Ol05) The ACORD name and logo dre reglstered marlcs of ACORD