The URL can be used to link to this page

Home My WebLink AboutApplication and WCj .�. ,, R�C�! � � TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSE/PERMIT -2017 ��u� �.',2 ��j 6 �� * Please complete form and attach all necessary documents by Dece ber 6 � Failure to do so will result in the return of your application pa EPT. ; ; . ESTABLISHMENT NAME: 2� TAX ID: � ' LOCATION ADDRESS: 13i� r :� �' , d-- �;,c,"�t, TEL.#: 50`d' �e� --C�CS MAILING ADDRESS: E-MAIL ADDRESS: OWNER NAME: � ' CORPORATION NAME (IF APPLICAB E): �Z„_- — MANAGER°S NAME: ��\ ��(� v.r Q.t1 TEL.#: p$ l00 C701� MAILING ADDRESS: 2, . 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 _ - —� -- _ _ _ _ _ ___------- _ - ----- _. ; 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 fbr 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. l�ill�am Sv�x-ot--zr�o�x�� 2._��d�c'� P�l� —T PERSON IN C�IARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. L � 2. � �(Y'�. ��,��,�P �` �� — - - -- . - - ---- - ----� --- - _ _�_ _ r _- �_ -_ _ ___ _ 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,�stablishments, 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. 1 � 0. 2. �2r r� �1�.�rn n -P e.�� .V 1 Gi T 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. T'0. �` C` 2. Q�.� ��,��`C. 3. '� r' 4. D'��rc� ..l'�\Cc��C -- RESTAURANT SEATING: TOTAL# OFFICE USE ONLY -- --�;a�c��:-- - --- — — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 _I� $55 CAMP $55 SWIMMING POOL$110ea. _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 ?—Ab�p �COMMON VIC. $60 �.� C� =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. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $ll0 NAME CHANGE: $15 AMOUNT DUE _ $ �Q ,QQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** n �� 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 F 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 APPROFRIATELY IF PAID: YES NO � � � � « �i 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 motei 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 ar . 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 Department 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.�armouth.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 REQLJIRED FEE(S) BY DECEMBER 16, 2016. � � 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 f TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. , ! ; DATE: SIGNATURE: � PRINT NAME & TITLE: ' ' Rev. 10/12/16 ' ; ' I �� ' � � �t � The Commonwealth of Massachusetts Department of Industrial Accidents ��LL �v� ! Office of Investigations ,,��/�, � M' ' 1 Congress Street, Suite I00 Y �'x Boston,MA 021I4-2017 www.mass.gov/dia ' . Workers' Compensation Insur,ance Affidavit:.General Businesses Auplicant Information Please Print Le�iblv Business/Organization Name:_�)�>\��' S ��ST(�l �'��.�.`(1� Ad�ess: t 3 o?Ll 1�-� . �� City/State/Zip:_s�1�.�n,.o�.�h. (Yl�}C��4Phone #: 5C�$ �'�C7 I�C� Are you an employer?Check the appropriate boz: Business Type(reqnired): 1.g I am a employer with��employees(full and/ 5. ❑ Retail or part-time).* 6.,�RestaurantlBar/Eating Establishment - �:u � ' � � �. ersiri�s�-id-irav��iro— _ _ - -- _ __ —--- 7. Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. �n�ertainment their right of exemption per a 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organizaxion, staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a --- , . a�-��forane-ye�---ir�prisonr�7er�t,-as w�it-as ci�i��natti�m th� �. a��'�3F zv�'0 n 3"��aiTd a�'r��- .� of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and ' s of perjury that the information provided above is true and correct. Si atur • Date: ' � Phone#: � �� `�l � D d Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office ' 6. Other Contact Person: Phone#: www.mass.gov/dia ' Client#:16383 2DOYLESRE7 AGORD,�� CERTIFICATE OF LIABILITY INSURANCE °°'�`"""'"'°"Y`"' � � � � �111A�2"/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMqTIQN ONLY AND CONFERS NO RIGHT$UPON THE CERTIFICATENOLDER.TH15 I CERTIFIGi4TE DOES NOT AFFIRMATIVELY�R NEGATNELY AMEN�, EXTEND OR ALTER THE COYERAGE AFFORDED BY THE POLICIE� BELOW.TW15 CERTIFICATE OF INSURANCE DOES NOT GONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S),AUTHORIZE`D REPRESENTATIVE pR PR�DUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)mu6t be endorsed.If SUBROGATION IS WAIVED,6ubjeGt t0 tNe terms and conditions vf the policy,certain poli�ies may require an endorsement.A statemertt on this certificate does not confer rights to the ce�tificate holder in lieu of such endorsement(s). �� MKODUCbK � NnOMN�ACT powling&O'Nei1 . � Dowling 8 O'Neil Insurance Agency v►,one 508 775-1620 `"" iNc,N�,e�iy: tac,noy: 5U87781218 973 lyannough Rd, PO Box 1990 t-M4�� ADDRES3: COi p�7doins.com Hyannis, MA OZ�O7 INSURER(3yAFFORDINGCOVERAGE NAICA ; 5os 7�s-�szo , �NsuKEK a:The Hartford 'i �NSUKbu IN3URER 8: ZDOM, I�c. D1B/A Doyla's Restaurant . �NSUNtN C: � A/O 6isque Boy Realty Trust 1329 Route 28 �NSURER D: � INSUKtK t: South Yarmouth, MA 0266.4 INSURERF� COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE PQLICIES OF INSURANCE USTED BELOW HAYE BEEN IuSUED TrJ THE INSURED NAMED ABOVE FrJR THE POLICY PERI4D INUICATEU. NOTwITHSTANUING ANY RE(3UIREMENT, TERM OR C(�NUffION OF ANY CONTRACT OR QTHER UnCUMENT WITH RESf�ECT TO WHICH THIS CERTIFICATE MAY BE ISSUEU OR R�AY f�ERTAIN, THE INSURANCE AFFnRU�U BY THE f�OLICIES UESCRIBEU H�REIN IS S�JB.IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITI�JNS OF SUCH POUCIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � �NS� TVPE OF INSURANCE AUUL udK rOUC�t�f vOUCv txr u H IN3R wV0 POLICV NUMBER (MM/uulrrrr} {Mn�luWrrrr) UMITS . GtNtFt4l L14lilU l Y � hA(:H()t:[:lll(fiFN(;f :� CnMMERCIAL GENERAL LIABIUTY DAM/+C�E 7 I7EN7ED MNFt�IitiF[- F-nrbimm�tc � [:I KIIW,i-N1KI1F n[i(:(:IIH I�q4111-%1'(NnY Mf`(1f:rFnn� ;� . MhH;i(1NW R A114 IN.IIIKv $ GENERALAGGREGATE $ i;�N•iai,i;H�i;ui�iiaaiic.rwi�;;vfH: rKius�ii;i.--Cii�ar,�CrNWc,c, $ roucv '`Hi'- �r�c s AU I OMOtlILt UAtlILI l V f.fJMH�NF13'iIN(il f I IIWI I (Ea a��vJ�di 1 ANY AUTO BODILY INJURY�f'w peiaunl $ ALL OWNED �CMEDULEC7 KIII():i /ilJl(l,i HC)I111 V IN.IIIF(V(vr.r,�r.r.vir.nt} b HIREDAUTqg WIIbI'i��~r" f•ei acudei+l•�rv��yr �' $ � UMHNELLA L�4tl QCCUR hliCH C}(;C;UNHFNCF $ � EXCE33 LU18 CLAIM�•MADE AGGREGATE '� ' DED RETENTi�JN y A WORKERSCOMFEN3ATIpN OSWECNL.�I$'IZ 6/01/2016 d6/01/201 )( �CSTATV• nTH• . ANUtMVLOYtKS'UAtl�U�Y Y�N I(1HVIIWII;s FH anrv�ki�rHo-�ciK;waH�N�w�x�C�iiv� E.L.EACHACCIDENT �50dbII0 �FFICER/MEMBER EXCLUDED? � N 14 (n�,na,�wy i�NN� F.i,i�r;�a4�.�a��ww i�rF� :650U 000 If yn+�,Jn�x:iiUn u�id� UF=;I:H'YII(')NOFOF'h/tHl'�.bN�StN11Dw E.L.DISEASE-f9LICYLIMiT ffi$OU,OOO UESCKIPI ION OF OPkK41�ONS/LOCAl16NS 1 V6HICLtS(4tlach�4COHU 101�AOtlll�onal Nomarkz SchaOulu,If mora spaco Iz raqulra0� ��C Operations performed by the named insured subject to policy conditions �,�� and exclusions. '€�.� 5 '� U� Cu�U HEALTH DEP7' CERTIFICATE HOLDER CAhICELLATION Town of Ya rmouth SHOU�D ANV OF THE ABOVE DESCRIBED PD�ICIES BE CANCELIEU BEFORE THE EXPIRA710N DATE THEREOF, NOTICE WILL 6E DEUVERED IN LiCeflSe D@pt. ACCORD4NCE WITH THE POLICV PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 4U�HOHICtU�ttwKk$kNI411Vt L F .�4 n 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(201 pJp5) 1 of 1 Th�ACORD name and logo are regictered marks of ACORD #S 1794 581M1794 57 CB D