The URL can be used to link to this page

Home My WebLink AboutApplication and WCi �� :, , ► TOWN OF YARMOUTH BOARD OF HEALTH �.;� - �� APPLICATION FOR LICENSE/PERMIT . O1 ;" ' - _ �� .:. �....o �'4 ,; b i ,.,-� `� �"n r�� * Please complete form and attach a11 necessary b r 1��I� �: Failure to do so will result in the return o L ur �ication p c et.�AL��pT. ESTABLISHMENT NAME: ��it,�P� lv�J�E�[-5 Pl�c�`S TAX ID: `�` : LOCATION ADDRESS: J� # to� S . � U.t TEL.#: dSs-�'Q y-7 J`��( ' MAILINCi ADDRESS: �iSl �'�torV-kv� S �t4r�a �Kk o z�i u ' O WNER NAME: 9N �> fi u� kt ',: CORPORATION NAME (IF APPLICAB E): S�,q�C.a�E �'✓P�I�IfS LLG ' MANAGER'S NAME: C'/u?�.y�- 1titv�PN��/ TEL.#: S�'�-6 y� � Y�/v MAILING ADDRESS: �! �"] �,t�1"�o.tr ,��_��s�o v?� I�.l „d1-- a l�C� 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 '' . _ __ ; ... . ___ _ _.-._.__�-�-_aw.._.�__ e:,-�-.. - ._�. �.,�� ...__ _- .�_.o.L:_ .. __ ._-_. - -.-- -_- �----. ____. . .. 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. 2. i 3. 4. ' F D PROTECTION MANAGERS - CERTIFICATIONS: 00 �11 food service establishments are re uired to have at least one full-time employee who is certified as a Food ; q 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 file at your establishment. ! � l. 2. ' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ': , 1 2 � ' . . ��_ _ - -_ --- - — _ - - _ _ _ __ - , -- - F � I�IMLICH CERTIFICATIONS: i 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 �le at your place of business. , 1. 2. _ ' 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 _MOTEL $55 INN $55 CA1��P $55 _SWIMMING POOL $80ea. LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. ' FOOD SERVICE: I LIC�NSE 12EQUIRED FEE P�IZMI'1'# L1CI:IVSL K�;(lUl ll rhL r�lu 1 1 ` — ZI ��v��;. � iiiREIS rnn - - .i � � 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80 , RETAIL SERVICE: —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 I <25,000 sq.ft. $80 � �OO _FROZEN DESSERT $40 �TOBACCO $95 �L3�6� NAME CHANGE: $ts AMOUNT DUE _ $ I"1 S �OO *****PLEASE TUI21V OVER AND COMPLETE OTHER SIDE OF FORM***** i �..�..'.---- — - — — , . �.. C� ; 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 t newal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: ' YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS I TRANSIENT OCCUPANCY• For purposes of the limitations of Motel or Hotel use,Transienf occu� anc shall be I� . p Y I, 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 I 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. � FQOD 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: I 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. i FROZEN DESSERTS: I Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results I; 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. i 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 j TO COMMENCEMENT. RENOVATIONS MAY IRE A SITE PLAN. DATE: i ti i 77� 1 Z SIGNATURE: PRINT NAME &TITLE: �} ! Lt,� r Rev. 10/09/12 � i � � : � CERTIFICATE OF LIABIL.ITY INSURANCE °A��i�2 Producer THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE AssociaUon Benefits Insurance Agency CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT 299 Bailardvale St,Suite 1 AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY Wilmington,MA 01887 THE POUCIES BEIOW. INSURERS AFFORDING COVERAGE NAIC# ��^� INSURER A: MA Retail Merchants WC Group inc. Seascape Spirits,LLC INSURER 6: dlb/a Seascape Wine&Spirits 4 Cariton Drive INSURER C: Norton,MA 02766 INSURER D: INSURER E: COVERAGES 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 7HE MSlN2ED NAMED ABONE FOR THE POLICY PERIQD INDICATED,NOlVNTMSTAN01NC3 ANY REQUIREMENT TERAA OR CONDI77pN OF ANY CON7RACT OR OTHER DOCUMEl�PT iMTH RESPECT TO WHICH THIS CERTIFlCATE MAY BE ISSUED OR MAY PERTAIN'17iE INSURANGE AFFORDED BY THE POIJqES DESCRIBEDHEREIN IS SUBJECTTO ALL THE TEFg1AS,EXCLUSIONS AND(�WDI710NS OF SUCH POl.ICIES. AGGREGATE LINqTS SHOYYN INAYHAVE BEEN REDUCED BY PAIpCLAIMS. poucr �ar� EFFECTIVE DRTE POUCY DfPIRATION M�t�7R Msko TYPE OF INSt1RANCE POLICY MJMBB2 DATE MI 1JMITS OBiERAL LIABILITY EAQi OCCUtI�lCE $ COMNIOtqAL C3EN�2AL LIABILITY FIRE DAM/�E(Any ane fre) $ CWMS MADE � OCWR MED D�(MY�P�'��J S PERSaNA1&ADV INJURY $ GENERAL AGGREOATE a GEN'L AGGR6GATE UMIT APPLIES PER: PRODUCTS—OOMPlOP AGG PRO- POLICY JECT LOC AUTOMO&LE W►BILITY COMBINED SINGLE UMIT $ ANY AUTO �E°°�^� ALL OVM�AUTOS 80�LV IN,0.1RY � 9q�tAED AUTOS �� MRED AUTOS BODILY IN.NIRY $ NONAI�R�AIJTOS (Pbr axidad) PROP62TY DAMAGE $ (Per eocidenU CiARAOE UA8ILITY AUTO O�LY—EA NCqDQJT $ AM'AUTO O7H92 THAN �� S Pd/T0 ON.Y pGG $ D(CESS LU1&UTY EACH OCCURRBJCE $ �� ❑ ��M� AGGREGATE a $ DEDUCTIBLE � � F�fBdl'ION S s WORK6t8 OOMPB�1&ATION AND WC SfATU- OTH- BitPLOYBtS LIABILPTY X TORY LIMITS B2 ANY PROPPoETBLPARTNQiID�CUfIVE EL.EACH ACqDH�IT A o�� 014005032844112 1/01/12 1/01/13 E�.a�-eo,ea�.ov� $ 1�,� �r r�,de�;ee urw,r NO SPE(�ALPROVISIONSbebw $ ��Q EI.DISEASE—POLICYUM�T $ 5pp,000 OTHER DE9CRIPTION OF OP67ATIOt�S/LOCATtON3/V6iICLE3l EXCLUSIONS ADOED BY ENOORSEMEM/S'P�CIAL PROVI�ONS CERTIFICATE HOL,DER ,00anor�a�ir��o:ir�i.Err�a: CANCELLATION SHOUID ANY OF THE ABOVE�SCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmoutl� THE EXPIRATIONDATE 1HEREOF,TME iSSU1NGINSURERIMLL ENDEAVORTO ��46 ROute 28 NIAIL 35 DAYS Y4RIT►EN N0710E TU 7HE CERTIFlCATE HOLDER NAMED SOuth Y8mloUth,MA 02664-4492 TO THE IEFT,BUT FAILURE TO DO SO SMALL IMPOSE NO OBLIGATION OR LJABILIIY OF RNY KIND UPON THE INSURER,ITS AOENTS OR REPRESENTATNES. AUTHORIZED REPRESENTATIVE ��