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Home My WebLink AboutApplication and WC �� TOWN OF YARMOUTH BOARD OF HEALTH �}W � L�^��^� � � APPLICATION FOR LICENS�'�� IT-20ll ��,�� , �v�i� � �o � �..�,�. � * Please complete form and attach a11 necess�do t��e e er �,�,��-�. Failure to do so will result in the return of your apphcation pac . ESTABLISHMENT NAM • c� � S s ! LOCATION ADDRESS: � TEL.#: � — Z" MAILING ADDRES • OVVIVER NAME: � CORPORATION NAM�ff AP LIC LE : MANAGER'S NAME: l�, TEL.#: � d MAILING ADDRESS: • 71, POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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 foiYil. 1. 2. Pool operators must list a minimum of two employees cun eiltly certified in basic water safety, standard First Aid aud Community Cardiopulmonaiy Resuscitatioii(CPR). Please list these employees below and attach copies ofemployee certifications to this foi�rn. The Health Department will not use past years' records. You must provide ne�v copies and maintain a �le at your place of business. 1. 2. 3- 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents are requued to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sasutary Code for Food Seivice Establislunents, 105 CMR 590.000. Please attach copies of certification to this ap�lication. The Health Department�vill not use past years' records. You must provide ne�v copies and maintain a file at your establishment. L 2. PERSON 1N CHARGE: Each food establislunent must have at Ieast one Person In Charge (PIC) on site duruig hours of operation. 1. 2. HEIMLICH CERTIFICATIONS: All food seivice 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 trauied in anti-chokuig procedures below aud attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide ne�v copies and maintain a �le at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGI\G: LICENSE REQUIRED FEE PERMIr# LICENSE REQUIRED FEE PERVIIT� LICENSE REQUIRED FEE PERiVIIT� _B&B S55 _CABIN S55 YIOTEL S5� _INN S5� _CA1�IP S5� _S�VLI�i;�IINGPOOL S80ea. _LODGE S» �I'RAILERPARK S10� ��HIRLPOOL S80ea. FOOD SER�'ICE: LICENSE REQL�IRED FEE PERMIT= LICENSE REQUIRED FEE PER�VIIT� LICENSE REQUIRED FEE PERI�IIT� _0-100 SEATS S85 _CONTINENTAL S3� NON-PROFIT S30 _>100 SEATS S160 _CO�VP�VION VIC. S60 ��'HOLESALE S80 RETAIL SER�'ICE: —RESID.KI?CHEN S80 LICENSE REQUIRED FEE PER'�IIr# LICENSE REQUIRED FEE PERv1IT.� LICENSE REQUIRED FEE PER'�IIr# _<50 sq.ft. S50 _>25,000 sq.ft. S225 VENDING-FOOD S25 '�,C25,000 sq.ft. S30 �� _FROZEN DESSERT S40 t--TT31�3ACC0 S» � ��zE c�vcE: sis A1�10UNT DUE = l � S�� *****PLEASE TL'R\OVER A�D CO�TPLETE OTHER SIDE OF FOR�1**"** t .. . ADMINISTRATION � 4 I Under Chapter 152, Section 25C, Subsection 6,the Town of Yannouth is now required to hold issuance or renewal j 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 j � Town of Yarmouth taxes and liens rnust be paid prior to renewal or issuance of your pernuts. PLEASE CHECK � APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS � TRAN5IENT 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 sha11 generally refer to continuous occupancy of not more than thirty (30) days, and an � aggregate of not more thari ninety(90) days within any six(6)month period. Use of a guest unit as a residence or ; dwelling unit shall not be consi�ed transient. Occupancy that is subject to the collection of Room Occupancy I Excise, as defined in M.G.L, c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. � POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected j by the Health Department prior to opening. Contact the Health Department 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. ! � ; �'OOL 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 1 closing. � i FOOD SERVICE � i SEASONAL FOOD SERVICE OPENING: � All food service establishments must be ins�ected by the Health Department prior to opening. Please contact the � Health Department to schedule the inspection three(3) days prior to opening. i � CATERING POLICY: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required j Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the ! Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department,Downloadable I, Forms. FROZEN DESSERTS: I 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 establishtnent is prohibited. NOTICE:Permits run annually from January 1 to December 3 l. IT IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED RENEWAL APPLICATION( REQUIlZED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD EST LIS N , MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.),MUST BE REPORTE TO OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS AY R R TE PLAN. DATE: � � II SIGNAT PRINT NAME&TI LE• eU�(,�f'.�l 10�06�10 -.. 07/29/2011 02:53 FA% 6174567815 ABI Office, 2, f�0002/0003 A�ORD CERTIFICATE OF LtABILfTY� INSURANCE �o�r�o�� PRODUCER Pnwix (817)458-7eoo Fax (81�456-78�5 THIS CERi1FICATE IS ISSUED AS A MATTER OF INFORMATION ASSOCUTiON BENEFITS INSURANCE AGENCY.INC. OI�Y AND CONFERS NO RN3H73 uPON 7HE CERTIFiCATE LYNNFIELD WOODS O�F10E PARK HOLDeR. THis CERTIFICATE DOES NOT AMEND, EXTEND OR 210 BROADWAY,sU1TE Z01 ER TF'��c 7HE P �iCIE e w IYNNFIELD MA 01940 INSURERS/KFFORDIN(3 COVERAGE NAIC�1 ngerwy uar ��e2so� INSURED INSURER/l: MassacF�usetts Refaii Merchanffi Workers Compe cn Group SEASCAPE 3PIRIT3 LLC INSURER B: DBA SEASCAPE WINE.AND SPIRfTS � INSURER C: 461 STATION AVENUE 1NSURER D: S011TFI YARMOTH.MA Q2644 INSURER E: covEw►�Es Th� POUCIES OF IN3URANCE LISTED BELOW HAVE B N IS UED T THE INSURED WWED ABOVE FOR 7HE POl1CY PERIOD INDiCATED, N0TIMTHSTANDIN(`i ANY REOUIREMENT, TERY OR COP�ITION OF ANY CONlRACT OR OTHER DOCIAMEN7 WITH RE8PECT TO WH�M 7HIS CER71FlCATE MAY BE ISSUED OR MAY PERTAIN, 7HE INSURANCE AFFORDED BV THE POLtCIES DESCRIBED HEREIN IB SUBJECT TO ALL THE TERM8, EXCIUSIONS AN� CON01T10N8 OF SUCH POLICIES. AGGRECiNTE LIMRB SH01MN MAY HAVE BEEN REDUCED BY PA�CLAIMS. LTR INS TY?E�INHURANCE POLICY NUMBER POLICY ERFEGTNE POLICY FXPIRATION UAbTS CENERAL WBLlTY EACH OCCURRENCE : COMAAERCIAL GENERAL LWBIIITY ��8 R� S • CLAIMS MADE Q OCCUR ��•�(MY�P�) S PERSONAL 8 ADV INJURY S GENERALAG6REGA7E S OEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS-COINP/OP/IGO. t POLICY PRO- `� s AUTOMOBILE LUIHILITY COMBINED SINGLE LIMIT ANY At1T0 (��) S AlL OWNED AUTOS B�II.Y WJURY SCHEDULED AU703 (P�Penon) t HIRED AUTOS 80D�Y INJURY NON-01MNED AUTOS (Per aeciderk) _ PROPER7Y DAMRGE s (Per aaidenl) f3ARAGE LIABlLITY = AUTO ONLY-EA ACCIDENT IwVAUTO O7HERTWW EAACC s AUTO ONLY: ,qC,G i EXCESSIUMBRELLALU161UTY �CHOCCURRENCE S OCCUR ❑CIAIMS MADE AGGREGATE 3 s DEOUCTIBLE � � S RETENTION S � s WORKERS COMPENSATfON AND 0140050328441-'11 06/01/11 01/01112 X mRr utia�ra °T'�R EMPLOYfiRS'LIABIIfTY E.L EACHACCIDENT S • 1OU�OOO A /M/YPROPRIETOR!►ARTIERIE7iffCUTNE oFFlc�tnxwaeR exa.uo�a E.L.OlSEA3E-EA EMPLOYEE S 100,000 a ya,auene.�.e.r SPEcu1LPROVIspMsbMaw E-L.UISEASE-POLICY LIMfT S SOO�OOO OTHER: DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED SY ENDORSEMENT/SPECIAL PROVISIONS CERTIFlCATE HOLDER CANCELLATION TOWN QF YARMOUTH SHOULD ANY OF Th�ABOVE DESCRfBED POLICIES BE CANCEIlED BEFOF�THE 1146 ROUTE 28 �x�►T�on�nieR�oF. n� issuwc a�,suR�rt wiu.�+n�von To Mna.�o a►vs WRITTEN I�710E TO 7'HE CERIIFICATE HOLDER NAMED TO THE LEFT,BUT FAlIXtE TO SOU7H YARMOUTH,MA 02664 uo so sru�u�►+�oeus�rron ort tu►eiurv OF rwr aND tmoN THE x+su�,trs AGENTS OR REPRESENTATNEB. AUTHORIZED REPRE3ENTATNE Atta►rtfon= Frank M.Venuto