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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH ��c��,� ' `, � � APPLICATION FOR LICENSE/PERI�I��T � 1 � �"� � � s �� tr ? y 7tlifi "'°' * Please com lete form and attach all necessary docu��+��Cswb�-�e e :: r 15 Z015. Failure to do so will result in the return of your ap}��ica�n-p etHEALTH DEPT. ESTABLISHMENT NAME: ` IJ G P TAX ID• �" .� LOCATION ADDRESS: � U� U C) C TEL.#: S - - MAILING ADDRESS: S R Y�.� E-MAIL ADDRESS: -� � DO a C'� OWNER NAME: CORPOR.ATION NA E (IF APPLICABLE�: � � � R. � l CC.� MANAGER'S NAME: �/CS }�� TEL.#: O � � MAILING ADDRESS: (a Z S� � l� 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. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. 3. 4• FOOD PROTECTION MANAGERS - 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. 2. PERSON IN CHARGE: Each food establishment must 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. l. 2. HEIMLICH CERTIFICATIONS: 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 file at your place of business. 1. 2. 3. 4. RESTAUR.ANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$1 l0ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f ADMINISTRATION 'Under�hapter 1,�2, S�ction 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal 'of any lic��se or pei'mit 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 1NSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 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 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 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 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. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Depaxtment to schedule the inspection three (3) days prior to opening. CATERING POLICY: 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 obtained at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. 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 of Health. OUTDOOR COOHING: 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 THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2015. 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 QU A SITE PLAN. DATE: 6 SIGNATURE: � (�it,/1�I(r� PRINT NAME& TITLE: ` 1/e ( �� . Q(,f/ Rev. 10/O1/15 � i � -- ---- -____------ ' '`�c�� CERTIFICATE OF LIABILITY INSURANCE °�'�`�"�°'"�'"' 5/12/16 T RTIFICATE IS ISSUED AS A MATTER OF II�ORMATION OI�Y AND CONFERS NO WGHTS UPON THE CERTIRCATE HOLDER TFRS ! FICATE DOES NOT AFFIRMA7lVELY OR NEGATIVELY AAAEI�, E)CTEI� OR ALTER TFE COVERAGE AFFORDED BY THE POLIqES �� LOW. TF�SS CERTIFlCATE OF INSURANCE DOES NOT CONSTITU7E A CONTRACT BETWEEN THE ISSUING INSURER(S), AUiHORIZED PRESENTA7NE OR PRODUCER,AND THE CERTIFlCATE HOLDER. ' �►VIPORTANT: If the certificate holder is an ADD1710NAL INSURED,ihe policy(ies) must be endorsed. If SUBROGA710N IS WAIVED,subject to ! the terms and con�itions ofthe policy,certain policies may rec�ire an endorsement A sta�errferrt on tMs certificate does not conkr righfis bo tl�e ' ? certificate holder in lieu of such endorsement(sy. % PROqJCER + NAIY�: R3 Travers Chagnon Insurance Agency, Inc. P�E . (�jOE) 771-1660 �'X N ; (508) 775-1135 � PO Box 355 AD��; raytraners@ciai.nsurance.net � 411 Route 28 INSURE S AFFORDINGCOVERAGE NAIC# West Yarmouth, 1� 02673 �r�R�a:Harford Insurance �Co �ratat� INSURER B: YI� Enterprises LLC i�Re�c: dba Big Al's Breakfast and Lun i�R�p: 1074 Route 28 INSURER E: So Yarmouth, 1+�. 02664 �NSURERF: COVERAGES CERTIFICATE NUMBER: REVtSION NUMBER: Tti1S IS TO CERTiFY THAT THE POLIC�S OF INSURANCE LISTED BELOW HAVE BEEN (SSUED TO THE INSIk�ED NAMm ABOVE FOR THE POUCY PERIOD INQICATm. NOTiMTHSTANDMG AN`f REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI'i'H RESPECT TO WHICH THIS CERT�ICATE MAY BE ISSUED OR MAY PERTAW,THE WSURANCE AFFORDED BY TFE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIT40NS OF SUCH POLICIES.LAVIffS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �LTR TYPEOFINSURANCE A�L� POUf.1f NUIIBER M�KEFF ��d�Y u�� A ��i4L1-1A'B��TM BEING ISSUED 5/18/16 5/ie/i� �cHoccuw�ce s 1 000 000 X COANNERCIALGENERALLIABII.ITY � DAM4GETORENTED $ lOO OOO CLAIMS-MADE �OCCUR . _. MED EJ�(Ary one persm) $ rj �0� r�SOw�La aoV IwURY $ 1 OOO OOO ceNEwu.AGCREcare $ 2 OOO OOO 6EN'LAGGREGATELMITAHPLIESPER PRODUCfS-CflIV�/OPAGG $ Q OOO OOO POLICY PRo- �p� S AUTOMOBILELIABILITY C IrBINED W L LIMR a axidert g ANY AU'Ip � - • BODILY INJURY(Per person) $ ALLOWPED SCHEDULED ' BODILYINJURY Peraccident $ AUTOS AUTOS � ( 1 HIREDAUTOS NON-OWNED PROPERf`f DAMAGE _AUTOS Peracciderrt � ' $ UNBRELLA uA6 Q��R EACH OCCURRENCE $ -" EXCESS LIAB CLAIMS-MA� AGGI�GATE $ DED RETENTION$ '�_ $ A uwRKERS coMPENsaTlow BEING ISSUED 5/18/16 .5/18/17 1Nc STaTu- pTH_ AND EMPLOYERS'LIABILII'Y Y/N �. _.a�nr�x�aiFrowaatn��cu-rn�.____. _ __500 OQOA___ �FI�RIN�MBER IXCLIAED? � N%A _ __ __ .__ _-- - - -- - '.- G.L.EACH ACqOEWr — .__ -g- (AAandaeory in NH� E.L.DISEASE-EA 9uPLOYEE $ 'Jr��,�� If Yes describeunder DESG�RIPTION OF OPERATIONSbelow EL.�ISEASE-POUCY L9�AR $ rJOO,OOO OESCRiPT10N OF OPERATIONS 1 LOCAT10N5/VEF9CLES (,4ttaeh pCpRp�p1,pdaho�al Rertarks gq�ed�e,if more apace is requ rad) Breakfast and Lunch Restaurant �. __ - <-a" CERTIFICATE NOLDER CANCEi.LAT10N ' SNOULD ANY OF THE AHOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DA7E THEREOF, NOTICE WILL BE DELIVERED IN i TOWn of Yarmouth ACCORDANCE WI7H iHE POLICY PROVISIONS. � Rt 28 � ; So Yarmbuth Ma. 026, Aun�or��r+�s�rn � i � �