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Home My WebLink AboutApplication and WC � � � R TOWN OF YARMOUTH B4 F HEALT.� � �� APPLICATION FOR LTCENSE ��T 20 � �y'�. A / � � - � "' � � ��7 4 ^ .. ^wy. -.� V �.�.e�tl ��1`.� / F� � *Please complete form and attach a11 necessary�ocui°rt'e�� `�c ` 1 S 2009. Faiaure to do so wilJ result in the return of your a p plication p . '``°- ° ' '�`'�� ' , - � `� NAME OF ESTA$LISHMENT:_ �.Q.l�.�c-t.� � �'� L �--�-- TEL. # �J��'�� d T�� . LOCATION ADDRESS: � ��64 �-� �- tlu %�1-1 �/�"c�r��-/ �� v ZCe Ce.�- MAILING ADDRESS: ?` ' � •' ' � OWNER NAME: � ��n� T��FEIN or SSN): � " CORPORATION NAME (IF APPLICABLE): ' MANAGER'S NAME: � � 1�1�� TEL. #, u U - ��- MAILING ADDRESS: � .e.. 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 co�y of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Comtnunity Cardiapulmonary Resuscitarion(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. �. a. 3. 4. FOOD PROTECTION�vIANAGERS - CERTIFICATIONS: 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 file at your establishment. 1. C,J 1�t�b t��" �. ��ll� 2. PERSON IN CHARGE: �ach food establishment must have at least one Person�n�harge (PIC) on site during hours o#operation. 1. 2. HEIMLICH CERTIFICATI4NS: All food service establishments with 25 seats or more must have at least one employee trained in the Hei.mlich 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 aot use past years' records. You must provide new copies and maintain �ffle at your place of business. 1. 2. - 3. 4. RESTAURA.NT SEATING: TOTAL# OFFICE USE ONLY LODGING: LIC�NSE REQtJIRED FEE PERMIT# LICENSE.REQUIRED FE$ PERMIT# LICENSE REQUIRED FE� PERMIT# �B&B $55 `CABIN $55 �MOTEI. $55 �INN $55 �CAMP $55 �SWIMMiNG POOI, $80ea. �LODGE $55 �TRAILBRPATtK $105 �WHIRLPOOL $80ea. FOOD SERVICE: LICBNS�REQLJIRED FEE P�RMIT# LICENSE REQUIRED k'£E PETtM1T# LICENSE REQUIRED FEE PERMIT# �0-100 S�ATS $$5 �j,0� _GONTINENTAL $35 �NON-PROfiIT $30 >100 SEATS $160 COMMON VIC. $60 WHOLESALE �80 RET.�11L SERVICE: �RESID.KITCHEN �80 LIGENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LTCENSE REQUIRED FEE PERMIT,# _„<50 sq.R. 550 >25,000 sq.ft. �225 _VENDING-fi00D $25 „^,<25,000 sq.ft. $80 rFROZEN DESSERT $40 TTOBACCO $55 � xAME c�Iatv��: $is AMOUNT DUE _ $ 85 .o 0 *"""*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*"** _ _ . "' � � i ADMINISTRATION U�d�r Chapter 152, Section 25C, Subsection b,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernrit to operate a business if a person or compa.ny does not have a Certificate of Worker's Compensation Insuraance. THE ATTACHED STATE WOItKER'S COMPENSATION INSURANCE AFFIDAViT MUST BE COMPLETED AND SIGNED, OR _f CERT. OF INSURANCE ATTACHED� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens znust 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 MoteI or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ord�naril�and customarily associated with motel and hotel use. Transient accupants must have and be able to demonstrate that they maintain a principal place ofresidence eL�where. Transient occupancy sha11 generally refer to continuous occupancy of nat more than t�rty (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, sha11 generally be considered Transieirt. 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 thr�(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER 1'ESTING: The water must be tested for pseudomonas,tatal coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to apening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimmin�pool must be drained or covered within seven(7)d�ys of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yatmouth rnust 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 obtained at the Health Department. FROZEN DESSERTS: Frazen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspen�sian ar revocation of your Frozen Dessert Permit untit the above terms have been met. UUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. ouTnooR cooxnvG: Outdoor cookin�,preparation,or display of any food product by a retail or food service establislunerrt is prohibited. NOTICE:Pernuts run annually from lanuary 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETURN THE COMPLETED RENEWAI,APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 1 S, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'TING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �� D�v ' DATE: � SIGNATURE: PRINT NAME&TITLE: 'v'`� 'J� � ` �� 09/25/09 f � � Client#:48248 CELISOL ACORD,M GERTIFICATE QF LIABILITY INSURANGE ��13�g�YYYY) PftODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So.Dennis QNLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 434 Route 134 HOLDER.THIS GERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDEd BY THE POLICIES BELOW. P.O.Box 1601 South Dennis,MA 0266Q-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: XS BfOIC@fS I�ISU�afICB A�B(IC�/ CeliacSolution,LLCi ItiSURERB_ 7 Rita Avenue �NSURER C: South Yarmouth,MA 02664 INSURER D: INSURER E: COVERAGES THE POLIC�S OF INSURANCE LISTED BELOW HAVE B�N ISSUED TO THE INSUI�D NAMED ABOVE FOR TF�POLICY PERIOD MDICAT@.NOTWITHSTANQIPIG ANY REQU�EMENT,TERM OR C�ffiON dF ANY CONTRACT OR OTHE3�DOCUMENT WITH RESPECT TO WHICH THIS CERTIF�ATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDEQ BY THE POLICIES QESCRIBED H�E9J IS St1BJECT TO ALL TI�TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE llMffS SHOWN AAAY HAVE BEBJ REQUCED BY PAID CLAIMS. LTR TYF�OF MISURANCE POLICY NUMBER ��Y EFFEC7IVE POLICY EXPIRATI6N V�Ts Y AT IYY A. GENERAL W161lfTT CL51559377 02l16l49 OZN6/iQ EACF1 OCCUf&iENCE S1 000 00� �( COMMERCIAL GENERAL LIA8ILRY � -� � D�A�GE TO RENTED $5O aQO cuv�us AUOE Q OCCUR MED ExP(Rnp one person? 55�QQ PERSONAI 8 AdV qdJURY S7 OOO OQO GENERAL AGGF�GATE $2 OOO QOD GEN'L AGGREGATE UIMT APPLIES PER: PRODUCTS-Ct�IPIOP AGG $Z WQ OOO POLICY jECT LQC . AUTONIOBILE LIABILITY COMBINED SlNGLE LIMIT ANY At1T0 �a��) $ ALL OVMIED RUTOS BODLLY IN.RIRY $ SGHEOUtEO AUT� ��P�O�� HIREQ AUTOS BODRY MIJURY $ N6N-OVWJED AttTOS (Per a�dderd) PRDPERTY DAI�IAGE $ (Per acdderd) GARAGE LIABILRY A11T0 ONLY-EA ACCIDEHT S ANY RUTO OTHER THAN �A� $ AUTOONLY: AGG $ EXCESSNM6RELlA LIABIL(TY EACH OCCURRENCE $ OCCUR ❑CLAIMS►�L4DE AGfiREGATE S $ DEQUCTBLE $ � RETENTION s s WORKERS COMPB�ISATION AND VMC S7ATIJ- OTH- ( EMPLOYERS'LIABfl_ITY A►dY PROPRIETQWPARTNER/EXECUTIVE � EL EACH ACCIDENT $ OFFICER/MEMBER EXCL4IDED? EL.�ISEASE-EA EMPLOYEE S if yes.desn�e�mder SPECL4L PROVISIONS bdow EL DISEASE-POLICY UMR $ OTMER DESCFBPTION OF OPERATIONS I LOCAT�NS 1 VEH�LES 7 DCCLUSIONS ADDEO BY ENDOIiSEMENT 1 SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOi1LD ANY OF THE ABOYE DESqtiBED POLICIES BE CJINCELLED BEFORE THE EXP�RATION FORINFORMATIONPURPOSES DATETHEREOF,THE13�lNi61NSU(iER7MLLENDEAVORTOMA� _j,Q_ DAYSWRITTEN NOTICE TO THE GERTIFICATE XOLDER NAME�TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPQSE RO OBLI6ATION OR IIABIIITT OF ANY KIND UPON TME INSURER,ITS AGENTS OR REPRESENTATIYES. AUTHORIZED REPRESENTATIVE f .. ACORD 25(2001108)� of 2 #4g355 �(py �ACORD CORPORATION 1988 IMPORTANT If the certificate hokier is an ADDITIONAL INSURED,the pol�y(ies)must be endorsed. A statement an this certificate does not confer rights to the oertficate hd�r in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and �nditions of the policy,certain policies may require an endorsement. A statemerrt on this certificate does not confer rights to the certificate holder in lieu of s�h endorsement(s). DISCLAIMER The Certif'icate of Insuran� on the reverse side aF this form does not constih�te a corrtract b�ween the issuing insurer(s), autharized representative or producer,and the ce.rtificate holder, nor does it affirmatively or negatively arr�nd, e�ctend or alter tt� wverage afforded by the pdiaes listed thereon. ACORD 25S(2001/08) 2 pf 2 #46555