The URL can be used to link to this page

Home My WebLink AboutApplication and WC� � �'' �' � � �� , � _ � j1tl, __ �* TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSE/PERMIT-2014 �� 0�3 `` * Please complete form and attach all necessar�;dac�e��,y`, ce Failure to do so will result in the,�x�t�caf�o�r�.ppli at 4 �-. ESTABLISHMENT NAME: P � ��y �� ' LOCATION ADDRESS: `1�6 M� r,v BrbQ,G�rt` TEL.#: Sc�- 7�8�- /S"'v� MAILING ADDRESS: , i /��o SS �' E-MAIL ADDRESS: su,a r:.r'Z zi C� u.o c _c.��. OWNER NAME: �A o cics�rJl+e, bJe te.t�f i CORPORATION NAME(IF APPLICABLE): ti d r�t �j„C ; MANAGER'S NAME: �,� �L �;�.,A R.,* � T�L.#:_5'QB--_�6�- �� G { MAILING ADDRES S: I o� t�.Z.ee-c�Nt PnN-t A �-e- C2.c�Z��v c c�� a o a6 3 2- I - , i { POOL CERTIFICATIONS: ; The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool i Operator(s)and attach a co y of the certification to this form. ( � � 1. v � S � 2. � Pool operators must list a minimum of two employees currently certified in basic water safeiy, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 times. Please list i the employees below and attach copies of their certifications to this form. The Health Department will not use past � years' ecords. You must provide new copies and maintain a file at your place of bu 'ness �/ ti;� � �� . �� z. 3. .�-> SS 4. vS`�Q.� N a FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is.certified as a Food Protectian Manager, as defined in the Sta.ta Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please atta.ch 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. � 1.��,�?� i sS� � 2. PERSON 1N CHARGE: iEach food establishment mus have at least one Person In Charge(PIC) on site during hours of operation. , � 1. ,�..� ✓ 2, _ ALLERGEN CERTIFICATIONS: � All food service establishments are required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. 1.�,�/,�,,v��-�t� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one erri�loyee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg 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. , j 1. c�i i iv� �iv �'�� S 2. 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 ( MOTEL $55 �r – ''1 INN $55 CAMP $55 �.SWIMMING POOL $80ea �t G'��G�} _LODGE $55 TRAILER PARK $105 1 WHIRLPOOL $80ea.� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# { 0-100 SEATS $85 #i �o '. ' _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $160 �COMMON VIC. $60 / –��' WHOLESALE $80 —RESID.KITCHEN $SO I RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# q >25,000 sq.ft. $225 VENDING-FOOD $25 <5 s . 50 <25,000 sq.ft. $80 _FROZEN DESSERT $40 �TOBACCO $95 NAME CHANGE: $15 AMOLTNT DUE _ $ �Z�.O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I . .:... . _:_ .,�,_, -�:,. T( � �. _ -- .. _ f 4 � ... � .. ' . :*,.` � � � � ADMINISTRATION +� ' . Under Chapter 15�,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of t any license or permitto 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 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED I E 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 sha11 be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel ancl 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 sha11 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 insp+ected 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 j 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. ' i i , i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of i closing. - ` - _ -- _ -- __ _ _ T6�D S�R�I�E _ __ 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. � i CATERING POLICY: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required i 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 Sta.te certified lab priar 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 4 THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 13, 2013. � � � i 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. RENOVATIONS MAY RE A SITE P . � DATE: �` Z� „�_SIGNATURE: �'�II�'I`N��E.&TITLE: �,� c. S w h R•t z.— �o � � 4 Rev.10/08/13 t k , � a. �,�.. _ � j , '. � �""'1 oocFca,ss-o� ocri A�„�.,..��y CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDM'YYY) a�2a2o�s ', THIS CERTIFICATE IS ISSUED AS A AAATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ' BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condMlons of the poiicy,certain poiicies may require an endorsement A statement on this certificate does not confer righffi to the cerGNcate holder in lieu of such endorsemen s►. i PRODUCER (508)852-8500 NAME: i Protector Group Ins.Agency PHONE Fnx ' 100 Front Street,Suke 800 ��° A�C No: Worcester,AAA 0760&7435 nno�ss: INSURE S AFFORWN6 COVERAGE �p INSURERA:AUBfltIC CI18f�� INSURED The Point Inc./Dockside Hotel Group,Inc. iNsu�e: SEE BELOW FOR ADDITIONAL NAMED INSUREDS INSURERC: j 476 Main Street iNsur�R o: West Yarmouth,MA 02673 INSURER E: i INSURER F: � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICfES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I INDICATED. NO7IMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS j , CER7IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND C�NDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �L7R TYPE OF INSURANCE POLICV NUMBER MNUp Y FF IIA V � UA,pTB GENERAL W1&LITY EACH OCCURRENCE S CAMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S CLAIMS-AAADE �OCCUR MED EXP(My one person) S PERSONAL&ADV INJURY S GENERALAGGREGATE i GEM�AGGREGATE UMIT APPUES PER: PRODUCTS-CAMP�P AGG S Poucv �O' toc y AUTOMOBIIE LIABILITY MBINED 1 LE LIMIT Ea ecadeM �'A�0 BODILY INJURY(Per person) S ALL OWNED SCHEDULED AUTOS AUTpS BODILY INJURY(Peraaident) S HIREDAUTOS ��WNED AUTOS PER ACG s S UM��B ��R EACH OCCURRENCE S EXCESS W1B CWMS-MADE AGGREGATE E DED RETENTION S = NIORKERS COMPENSATION WC SfATU- OTH- AND EAAPLOYERS'IIABILlTY Y�N X Y IMI A AOP�FICER M�BE��EAXCLUD�C�� N f A V��06�� 4/1/2013 4N/2��4 E.L EACH ACCIDENT S �,� (Mandatory M NH) E.L DISEASE-EA EMPLOYE S SOO,O rc yes,desWbe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMR S SOO,O DESCFtIP710N OF OPERATIpNS!LOCATIONS/VEHICLES(Atfaeh p(�Rp 101,Addkbnal Ramarlcs Schadule,fl more apace k reqWrad) Named Insureds on above workers compensation policy are Dockside Hotel Group,Inc.,and The Point,Inc.,476 Main St,West Yartnouth,MA. , 02673,Cape Town 8 Courrtry Motor Lodge,Inc.,452 Nlain St,West Yartnouth,MA. 02673 and Mariner Motor Lodge,Inc.,573 Main St,West Yarmouth,AAA. 02673 CERTIFICATE HOLDER CANCELLATION , SHOULD ANY OF THE ABOVE DESCRIBED POIICIES BE CANCELLED BEFORE Dockside Hotel Group,(I1C.,Cape Town& THE EXP�RAT��N DATE THEREOF, NOTICE WILL BE DELNERED IN ' Country Motor Lodge,I�1C., ACCORDANCE WITH THE POLICY PROVISIONS. Mariner Motor Lodge,lnc.,the Point,Inc. 476 Main Street AUTHOWZED REPRESENTATIVE West Yarmouth,MA 02673- ��- � _ � O 1988-2010 ACORD CORPORATION. All rights reserved. , ACORD 25(2010/05) The ACORD name and togo a�+e registered marks of ACORD