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Home My WebLink AboutApplication and WC� , � � C � ► � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENS��,lI��2NHRT -�1�;�� 5 � 7 * Please complete form and attach all nece��'d��e��b�1��.� ibe' �PT � Failure to do so will result in the re�n of�Q��;a�ic��p . ESTABLISHMENT NAME: TAX ID: � o�c7 (o LOCATION ADDRESS: ,'Sk''S I�YIQ � � �5-�►',PP t: TEL.#: SU�1�77 /- 5�3C' MAILING ADDRESS: E-MAIL ADDRESS: �arm�u �ds-�,r�� rr,�ti��t�, ( , c.�r�i OWNER NAME: ' �L�VGt n��(,� n m�%, 5 CORPORATION NAME IF APPLICABLE): MANAGER'S NAME: � �j� s TEL.#: 5�� 365/-�7 .( MAILING ADDRESS: 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 for Food Service Establishments, 105 CMR 590.000. Please attach capies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a �le at your establishment. 1. 2. �Y I�l�(�. �S 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. 1. `�� --r rL� z. 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. �i✓�� Gyr DLta 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY � .. --- - - -- - — _ _ - - --- - -- - 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$110ea. _LODGE $55 _TRAILERPARIC $]OS _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 T>100 SEATS $200 ��j �COMMON VIC. $60 �p _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. $I50 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ 2�0.�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** F ` r 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 Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V 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,ardinarily 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. ; 4 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 priar 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 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 COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � NOTICE:Permits ru�annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN ' THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 16, 2016. � � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL R POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED B T OARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQU SITE P A , DATE: ��a�p I l�SIGNATURE: ! PRINT NAME & TITLE: �� I�IL ! Rev. 10/12/16 i .4co� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYI� `� 10/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY 012 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), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certi�cate 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 requlre an endorsement. A statement on this certiflcate dces not confer rights to the certiticate holder in lieu of such endorsement(s). PRODUCER NTACT NaME: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY PHONE : ��jOH�77�J-'IBZO F"" A/C No: n�o�ss: Isullivan doins.com 973 IYANNOUGH RD. INSURER S APFORDING COVERAGE NAIC S HYANNIS MA 02601 iNsuReRa: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: RED FACE JACKS INC DBA RED FACE JACKS INSURERC: �. INSURER D: � C O THE YARMOUTH HOUSE 335 MAIN STREET INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 93171 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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. �� INSR TypE OF INSURANCE �DL SUBR POLICY EFF POLICY EXP L71t POLICYNURABER MM/DD MM/DD ��M�TS COMMERCIAL GENERAL LWBILITY EACH OCCURRENCE $ M D CLAIMS-MADE OCCUR PREMISES Ea occurrence S j MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑�E a � LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILELIABILITY COMBINED S�NGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per persan) $ ALL OWNED SCHEDUIED AUTOS AUTOS N/A BODILY INJURY(Per acddentj $ NON-OWNED PROPERTYDAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LtA6 OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N!A AGGREGATE $ DED RETENTION$ $ WORKERSCOMPENSATWN X $TATUTE ERH AND EMPLOYERS'W►BILRY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ SOO,OOO A OFFICER/MEMBERFJ(CLUDED? MlA WA N/A 6S62UB9F70437916 05/16/2016 05/16/2017 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POIICY LIMIT $ SOO,OOO N/A DESCRIPTION OP OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schadule,may be altacF�ed if mwe space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay daims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This cert�cate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 �"� C Daniel M.Cro y,CPCU,Vice President—Residual Market—WCRIBMA O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD