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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSEIPERMIT-2017 *Ptease complete form and attach all necessary documents by DeremBer 16 2D16. Failure to do so will result in the return at your applicatian pac et. ESTABLISHMENT NAME: LOCATTON ADDRES5: 33S YY1c1�n PP� TEL#• SC�"`17I`S►� MAILING ADDItESS: E-MAIL ADDRESS:��'p�-� �� Q�Q , ��yy1 OWNER NAME: � CQRPORATION NAME�IF APPLICABLE): � ,e MANAGER'S NAME: 1 +r� � s �L.#: MAILING ADDRESS:_ 1`�P_ PO4L CERTIFICATIONS: The poal snpervisor must be certified as a Pool Operator,as required by State law, Please list the designated = �4�: ,�7 Pool Operator(s)and attach a copy of the certification to this form. � ,�.. � r � 1. 2. _ `_`' IT1 Pool operators must list a minimum of two emptoyees currently certified in standard First Aid and Community � �� Cardiopulmonary Resuscitarion(CPR),having one certified employee on premises at all times. Please list the Z7 �-� P'�`d employees below and attach copies of their certifications to this form.The Health Department will not use past -� .n �� yesrs'records. You must provide new copies and maint�in a�le at your piace of husiness. 1. 2. ,�;��'a 3. 4. �� .� FOOD PROTECTION MANAGERS-CERTIFICATIONS: � � All food service establishments are required to have at least one full-rime employee who is certified as a Food � ~ % Frotection 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 nse past years'records. ��"�"` You mast provide new copee an maintain a file at your establishment. .� �,,(,� � _;�....� i. ` ' �r�C�i�l (l(�� 2. O Q �V l�� t -�+ PERSON IN CHAR.GE: Each food establishment must have at least or►C Person In Charge(PIC)on site during hours of operation. �.''�`�,rSC�2r1 �.�. a. ALLE1tGEN CERTIFICATIONS: Atl food service establishments are required to have at least one full-iime employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.0�9(G)(3)(a). Please attach ' copies of certification to this applicarion. The Health Department will not use past years'records. Yoa mast provide new copies and maintain a file at your establishment. -, �.�' r�� ,�nc�,,,C� C 2. HEIMLICH CERTIFICATTONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Matzeuver on the premises at all times. Please list your employees trained in anti-choking procedures below snd attach copies of employee eertifications to this form. T6e Health De artment will not use past years'records. You�nust provide new copies and maintnin a file at your pluce o�business. 1."��- 7�.trY1,�P �� 2. �Yt� 1�0►+�.Y1dl�.l, � 3• 4. RESTAURANT SEATING: TOTAL# OFFIC�USE ONLY LODGING: LICEN5E REQUIRED PFG PERMIT# LTCBNSE REQUIRED FEE PEitMIT# LICGNSE REQLJ(RED FEG PERMIT# _B&B S55 CAB]N S55 M07EI. 5110 INN �55 "CAMP �55 ,,SWIMMI*1GPOOL$IlOex. �LUDGE SSS TTRAILER PARK SI05 �."_�"�_— ____WFi1RLPOOL St t0ea.__._._........._ FOOD SERVICE: LICENSE REQ UIRED FEE PERMIT# LICENSE REQUIRED FEE 1'EI2IvtIT# LICEN5E REQ U[RED FGL PF.RMIT# 0-100 SEATS 5125 CONTINE]V1'AL $35 NON-PRUFI'I' S30 =>100 SEATS $20Q �� COMMON V1C. Sb0 �DS —WFTOLF..SAI.E $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIR&D FEE PERMIT# LICENSE REQUIREU E'EE Pt�RMCT'k LICENSF.REQUIRF,D FEE f�ERIv1IT t! <50 sq.ft. S50 >25,000sq.8. 5285 ,-- YENI7INCi-FOOr7 $25 ___..._....._... =QS,UOOsq.ft. 5150 =PROZENDESSERT S40 _iTOBACCO $ItU NAME CHANGE: $15 AMOUNT DUE _ � �� *****PLEASE TURN OVER ANp COMPL�1'E 01'HBR S1UE OF'FOItM***"' An�Mi�+r�sTxATto�v Under Chapter 152,Section 25C,Subsection 6,the Town of Yannouth is now required to hold issuance or renewal of any license or perrnit to operate a business if a person or company does not have a Certifcate of Worker's Compensation Insurance. THE ATTACHEI'f STA1'I+. WORKER'S C4MPENSATIQN INSURANCF, AFI+IDAVIT MUST B�COMPLF..TED AND SIGt��D,OR / / CER'I'.QF INSURANCE ATT�ICHED n� OR WORKEK'S CQMP.AFFII7AVTT SIGNF.,T)ANll A'I I'ACHED Town of Yarmnuch taaces and liens must be paid priar to renewal or issuance of your permits. PLEASE CH�CK APPRUPRIATELY IF PAID: YES NO MUT�LS AYD pTHER LODGII�IG ESTAB�.ISHMENTS 'I'RANS.iENT OCCUPAIVCY: For purposes ofthe limitations nf Motel or Hatel use,Transient occupancy shall be limited ro the temporar}�and short term occnpacicy,ordinarily and customtu•ity associated with motel and h�te(use. Transient occupaztts must have and be able tn demonstcate that they maintain a principal place nf residence elsewhere."fransient ctecu�ancy shnli general ly refer to continuous occupancy of not more than thirty(30)ciays,and an a�;gregate af not more than ninety{9Q)days within any six(6)month period. Us�nf a guest anit as a residence c3r dwelting unit shail not be considered transient. Occupancy that is subject to the collection of Roam Occupancy Excise,as defined in M.G.L.c.64G ar 83Q CMR 64G,as amended,shalt generaily be considered Transient. POOLS PQQL OPENING:Atl swimmin�,w�ding�nd whirlpools which have been ctosed for the season must be inspected by the Health Departmentprior tn opening. Contact the Health Department to sshedule the inspection three(3) days priar to openiug.PLEASE I'�fUTE:People are NOT allowed to sit in the pool area until the pc�ol has beeu inspected and opened. POOL WATER TESTING: The water rnust be tested for pseudamonxs,total catiform and standard plate couni by a State certified lab,and subrnitted io the Health Dep�artment three(3}days prior to opening,and quarterly thereafter. PUOL CLOSING:Every autdoor in ground swimming pooi must be drained or covered within seven{1)days of closing. FUQD SERVICE SEASONAL FOOD SERVICE OPEN�3VG: All food service establishments must be inspected by the Health Department prior tv opening. Please contact the Fiealkh Department to scheduie the inspection three(3)days priar to opening. CATERING POL[CX: Anyone who caters within the Town of Yarmouth must notify the Yarrnouth Health Departrnent by fiting the requ�red Temporary Foad Service Application form 72 hours priar to fhe czctered event. 'I'hese forms can be obtained at the Health Departmeni,or from the Town's website at tivww.varmouth.ma.us uncier Health Department, Downloadable Porms. FROZ�N DESSERTS: Frozen desserks must be tested by a State ce�tified lab�ari�r to opening and monthly thereafier,with sampl�results submitted to the Health Uepariment. Faiture to do so will resuit in the sucpension or revocation of your T'rozen Desseri Permit until ths above terms have been�net. OUTSIDE CAF�S: Outside cafes(i.e.,outcioar seating with waiter/waittreess service),must have priar approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,prepararion,�r display of'any fpod product by a retaiI or faod service establishrnent is prohibited. NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESF4 SIBILITY TO RET'UItN THE COMPLETED KE:NEWAL APPLICATtON(S)AND REQLIIR.ED FEE(S)BY ECEMBER 16,2016. ALL RENOVATIONS T'O ANY FOUD ESTABLISHMF,NT, M(7TEL OR P ('e., Pt11INfiING, NEW EQUIPMEtv'T,E'Tt;.),MUST BE REPORTED TO ANI)�1PP OVED BY TH�E OF HEALTH PRIpR � T�COMMENCEMENT. ItENOVATIONS MAY REQU F., 'E 1'LAN. DATB:��_SIGNATURE: FItINT NAME&T'I'TY.E:�� (,'�___ ,��(��,yy�,b,� � �� Rcv.t�12l16 Client#:20816 2YARMHO ACORD� CERTIFICATE OF LIABILITY INSURANCE °"�`""""°°""'"' 70/12/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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),AUTHOR�ZED REPRESENTATIVE OR PRODUCER,AND THE CERTiFICATE HOLDER. IMPORTANT:If the certiflcate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the ceRificate holder in lieu of such endorsement(s). PROWCER Dowling&O'Neil Insurance Ag �rr� e 873 lyannough Rd,PO Box 1890 �i+o e�:508 775-1620 �,�,�,: 50877$1218 ADDRESS: Hyannis,� OZ6�� INSURER(S)AFFORDINGCOVERA6E NAIC� sos ns-�szo iNsuReRn:Tudor Insurance Company iNsur�o iNsuReR e:Guard Insurance Group Kounadis Enterprises,Inc.D/B/A INSURER C: Yarmouth House Restaurant 335 Main Street INSURER D: West Yarmouth,MA 02673 INSURER E: INSURER F: COVERACaES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �N� TYPE OF INSURANCE ADDL UB POLICY EFF POL�Y EXP �T� INSR NND POLICY NUMBER MMID MMIDD V�� . A GENERAL LIABILITY PGP0823822 /07/2016 04/01/201 EACH OCCURRENCE S'I OOO OOO X COMMERCIAL GENERAL LIABILITY PREMISE�EaEoa��ence S'IOO OOO . CLAIM&MADE a OCCUR MED EXP(My one person) S S OOO PERSONAL 6 ADV INJURY i� OOO OOO GENERALAGGREGATE tY�OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG SZ�OOO�OOO POLICY j� LOC E AUTOMOBILE LIA8ILITY �EOM�BI'Nd��INGLE LIMIT : ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY Per acddeM E AUT0.S AUTOS ( 1 NON-OWNED PROPERTY DAMAGE f HIRED AUTOS AUTOS Pe�a�ident S UMBRELLA UAB p�CUR EACH OCCURRENCE S ��ss��B CLAIM&MADE AGC�REGATE i DED RETENTION$ f B WORKERSCOMPENSATION KOWC727GO7 5/01/2016 05/01/201 X �STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER7EXECUTIVE Y�N E.L.EACH ACCIDENT t.SOO UOO OFF�CERIMEMBER EXCLUDED? a N/A (Ma�Watory in NH) E.L.DISEASE-EA EMPLOYEE SSOO OOO DESCRIPT$O OOPERATION$b�ow E.L.DISEASE-POLJCY LIMIT S.SOO,OOO A Liquor Liability PGP0823822 01/2016 04/01/201 s1,000,000 per occ a2,000,000 eggregate DESCRIPTION OF OPERATIONS/LOCAT10N3/VEHICLES(Attach ACORD 101,AddWonal RernaAcs Schedule,i(more cpace k requlred) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certiflcate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DE8CRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE iHEREOF, NOTiCE WILL BE DELIVERED IN 1746 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE �..,,� ��---�r �1988-2010 ACORD CORPORATION.Aii rights reserved. ACORD 2b(2010/Ob) 1 Of 1 The ACORD name and logo are registered marks of ACORD #5178054/M178053 LS1