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Home My WebLink AboutApplication and WC r . ... { C �:`.�.t�$#,1l�taA6E � TOWN OF YARMOUTH BOARD OF HEALTH ` - — � � APPLICATION FOR LICENSE/PERMIT- 11 � ' ; �EC 3 0 2010 � � �I ,-.� � � 3 2�01.�� . * Please complete form and attach a11 necessary docuinent�l�y�Dece ber, ,.�_ ; Failure to do so will result in the return o�'yo��ap�'lication p '��" '' . . ESTABLISHMENT NAME: TAX ID: �`�� ° LOCATION ADDRESS: �'�1- �L�� L/J �� TEL.#: S�� -7�( —d�' a L MAILING ADDRESS: S' OWNER NAME: �-.;�� Z�G'��,.- �L�� f CORPORATION NAME (IF APPLICABLE): ��—•.•�C � � I MANAGER'S NAME: �K !��- TEL.#:,�'d� ��7 r �-�10� ' MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool OperRtor,as required by State law. Please list the designated , �col C3�e��rrn�(s) ��3d atta�ra �opy-of t�e certtf�a�ron to t?�is fo��3. -- -- ,�� 1 1 t,uu..�� 2 2. � . , � Pool operators must list a muiimurn of two employees cun ently certified in basic water safety,standard First Aid aud ; Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee i certifications to this form. The Health Department witl not use past years' records. You must provide new '� copies and maintain a file at y�our place of business. ! 1. ��u�- 2. ��-� 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requued to have at least one fiill-time employee who is certified as a Food Protection Manager, as defined :ui the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000. ; Please attach copies of cei-tification to this application. The Health Department�vill not use past years'records. You must provide new copies and maintain a file at your establishment. i 1. 2. ; PERSON IN CHARGE: 4 , - -- _ , �ach food establislunent must liave at least one Person Iil Charge (F'IC j on site duruig�lours of operation. 4 I 1. 2. I HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in tlie Heunlich Maneuver on the premises at all times. Please list yow employees trained in anti-choking procedures below and atfach copies of employee cei�tifications to this form. The Health Department will not use p�,st years' records. You must provide ne�v copies and maintAin a �le at vour place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY ', LODGI\G: LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERVIIT# LICENSE REQLTIRED FEE PERI�III� _B&B S55 _CABIN S55 ( MOTEL S55 �6�Fa� ' _INN S55 CAMP S5� -"�'��____ v Z S��'IMNIING POOL S80ea. ��,, LODGE S�� TRAILERPARK S10� � �«�HIRLPOOL S80ea. �Q� FOOD SERVICE: '/ r LICENSE REQUIRED FEE PERMIT*� LICENSE REQUIRED FEE PER��ZIT� LICENSE REQUIRED FEE PERiviIT# _0-100 SEATS S8� _CONTINENTAL S35 _NON-PROFIT 530 �>100 SEATS S160 �� COMMON . S60 !'�F 'Q�? �'�'HOLESALE S80 RE?t1II.SER�'ICE: YIc��Gu'e� —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERNIIT� LICE REQUIRED FEE PER�IIT� LICENSE REQUIRED FEE PER'VIIT� _<50 sq.8. S50 _>25,000 sq.i�. S225 _VENDING-FOOD S25 _<25,000 sq.ft. S80 _FROZEN DESSERT S40 _TOBACCO S» �AVIE CHA\GE: S15 AMOUNT DUE _ $ 5 l S.O� *****PLEASE Tti'R�O�'ER A\D CO�IPLE?E OTHER SIDE OF FOR�i***** �_ r _ u � � 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 �"" i pR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: YES �`-., NO i 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 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, shall generally be considered Transient. POOLS j 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 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 I! thereafter. ' � POOL CLOSING: Every nutdoor 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 i Health Department to schedule the inspection three (3) days prior to opemng. � i CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yannouth 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.varmouth.ma.us under Health Department,Downloadable Forms. i 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. � - _ __------- _ -- -- -___ OUTDOOR COOHING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. I I NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RET[TRN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. i ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, 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 REQUIRE A SITE PLAN. DATE: !l��;SC,� SIGNATURE: PRINT NAME&TITLE: �`�`��-d1y�°� � 10�06'10 ' I ' ' DEC. 30. 2010 1 :56PM , HART INSURANCE � N0. 391 P. 1 acaRfl„ �EaTIFiCATE O� LIABILITY �NSURANCE °"'�`"'�°°"""' 1?l30/2010 Pxo�uc�e THIS C�R�7FiCATE tS ISSUPA AS A NIAT'C�R OF lNFORIAATtON HART(MSURANCE AGENCY, INC. ONLY AND c�aFERs NO RI�HTS uPON 7tie CE�TIFiCATE �4�MAlN STREET MOLDER. TFM3 CERTIFlCATE DO�S NOT AYEND, FX'i�ND OR ALTER THE COVERAGE AFFORDED HY TF1E POUC�ES BEWW. PO BOX 700 SUZZARDS SAY, MA Q2532-0T40 INSURERS APF�RDu+16 GO''V�RAQ�G � KNG� '"s�° Irish 1lilage Restaurant and Pub,ir�. �n�sureErt�: GRANI'fE AZ'E hl iJRAN 23809 512 Main Street �r�� West Ysrmouth,MA 02673 � e c: �Nsur�R a �ER E GOYERAGES TNE POLICIES OF INSt1RANGE U&TED BELOW MAVE 6BEN ISSUED TO TME WSURED NMAED ABOVE Fat 7NE POIiCY PERIOD INDICA7'Ed.b10T1AATFl$'TANDI�Ki ANY REQUIREMENT, TERl�f OR CbNDf110N OF ANY CONTRACT OIR OTIiffR DOCI�AENT Wff}1 RE.RPECT TO WHICht 7T1�CERT��'i'E MAY BE ISSIl6D OR MAY PERTAIN,YMB INSURANCE AFFORDED BY TNE POLICI�S DESCRIBED MERErV IS SUdJECT TO ALL T1iE TER1A8,�XCLU810N3 AND CONDRIONS OF SUCii POLICIES.AGGREG�ATE LWY'fS 8HOWN MAY HAVE BEEN R�D11CB0 BY PAID CLAiAS. tNSR POtICYfAN� P� PONC1'OWIRA � GENERAL ltA�i'TY EAp1 OOL�IRRFJ�E f Cor��rtcu�c�c�Rat w,eiutY i��M.nea � CIA��$MADE ❑OOCtlR M EXP ana pereaN 5 PERSOf�41L i AOV�JU� S GENHRALA40RE6A i GENL AGGftE(3A7E LIM[f APPL�S PER� •COF/P/OP ACi6 f POLICY LOC AUSOk10BIL6 LJA&LIry ( �y'BNrC,'!E LliiqT s ANY AUTO ALL ONAVED A!lTC15 . ��Y�� S SCHEDULEG AU70S �� HrRED AUTOS 80a��WURy NON-0WNEQ AUTOS (Paraoadony s ��OAMA3E : G0.RlIQE LNBRRY AUiO dN.Y-EA ACdOEKf i ANY AUfO E4 ACC 5 OTMER TMAN A�ITO O�N.Y� �� s EXCESS+tJM6REW1 WHLLnY �{p�R�' � OCCUR �CUUaAS Mo.DE AOGRE� '�& i s DEDl7CT18LE s RETHNTION f s A WORl�tSCO11PBiSATIONAND 1/1I�CQ4S855Q77 04/01/10 Q4/09/11 �� " °T� �� ANY PROPRIETORJPARTAtERlE7fECtlllvE E.L ACqOEN7' S O��CER/MRJ�IOER EXCCUOED7 @.L.OISEABE-(U1 EMPLOYEE S I/y�,daeubs ufA9r 3PEGA PROVISIONS Edew El a3EASH.POLICY llMd'T S O1HER DESCRIPTION OR OP@RATIONS 1 LOCATIONS!YEMOCLES!lXCLUSIONS ADD�BY !SPECW.PRdMIS10!/S CERTfFICATE HOLDER � CANCELLATION s�.o�unr ae n��seve o�rax�s s�eu+�um a�rN�o�Men� 70WN 0�YARMOUTH °it�r�''"e�ssw'c°u�'�""`L E"°e"va`r°"w' 34 °"rs w�' 1146 MAIN STREET ��ro�c�ut��wweo rn rNa�r.ws wuu�e To��u S YARMOUTFf, MA 42673 �M►Ou NO 061J3Af10N O!!WYLfIY Of NK Rq1p UpO/�TI�NlgfIRER�RS/�l�lTg pt �(iA AVyM01tBdD RE!'1FEi ACORD 25(2401/OS) �qCORD CORPORATION 1988