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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF AEALTH APPLICATION FOR LICENSE/PERMIT-ZO1T �`Please complete form and attach all necessary documents by Decembe�l6 2016. Failure to do so witl result in the retum of your application pac et. ESTABLISH1vvIENT NAME: �' R, LOCATION ADDRESS: .�� RU�,lT'� 62$ /i(/ �Vi4,e.nan�tr�tl TEL.#: �'08 ��S'GYo1J MAILING ADDRESS: �MAIL ADDRESS: 2 r'�� 7GViuGh7SPr�rT�. GOM OWNERNAME: ER.�IL Jr?,�-lN.t('('�N _/�ICGAkR�'N CORPORATION NAME(IF APPLICABLE): l UC}- T �Pl�l� �G e MANAGER'S NAME: C G I� TEL.#: / 6� MAILING ADDRESS: LL IUI v POOL CERTIFICATIONS: The poot supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pooi Operator(s)and attach a eopy of the certification to this form. i. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid attd Community Cardiopulmonary Resuscitation(CPR),having one certified employ�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 paat = �� 7 years'records. You must provide new rnpies and maintain a file at yonr place of bnsiness. � �= t'T'1 1. 2. 2 •_ �3'i 3. 4. C7 `�' � � �=' � FOOD PROTECTION MANAGERS-CERTIFTCATIONS: � '�'' � All food service establishments are required to have at teast 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. T6e Heatth Department will not nse past years'r�ords. _`� You muat 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. p .,. ..�.- ,. ... 1. 2. p� f, ...� ALLERGEN CERT'IFICA'TTONS: �J ; All food service establishments are required to have at least one fu11-time employee who Las Allergen certification, � as defined in the State Sanitary Code for Food Service Fstablishments,105 CMR 590.009(G)(3xa). Please attach copies of certification to this application. The Health Department wiU aot use past years'records. You must provide new copies and maintain a file at yonr establishmen� 1. 2. HEIlvILICH CERT'IFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at ali times. Please list your enployees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Healt6 Department will not nse past years'records. You mast provide new copies and maintain a file at yoar place of basiness. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# i.oncwc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �B S55 CABIN S55 MOTEL SI10 INN S55 CAMP S55 _SWDNbIIIQG POOL S110ea I.UDGE S55 �I'RAII.ERPARK S105 _WHIRLPOOL S1IOea FOOD SERYICE: LICENSE REQU(RED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REO[IIRED FEE PERMIT# a�oo sEn�Cs 5125 _CONIINENTAL S3S NON-PRO�1T S30 >100 SEATS SZ00 _COMMON VIC. S60 —1VHOLESAI.E S80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE �1��gg'MM�#Q LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# �'<25,OOO�sq.ft. Ss50 �^�J �ROZEONDESSERT�S40 =TOB CO F� 5110 � NAMECHANGE: SIS AMOUNTDUE _ $ {�saO.00 *+*+;PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM";'•* � ADNIII�iISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issoance 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 � ' 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 OCCUPANCI': For puiposes of the lunitations of Motel or Hotel use,Transient occu�ncy shall be limited to the temporary and short term occu�ncy,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 tlurty(30)days,and an aggregate of not more than ninety(90)days within any six(�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 pnor to opening. Contact the Health DW eparhuent to schedule the inspection thr�(3) days prior to opening.PLEASE NOTE:P�ple are NOT allo ed to sit in the pool area untii the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,totaI 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 ciosing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: ' All food service establishments must be inspected by the Health Depardnent prior to opening. Please contact We Health Department to schedule the inspection three(3)days priar to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Seivice 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.yazmouth.ma.us under Health Departinent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opeuing and monthly thereafter,with sample results submitted to the Healttt Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pernut until the above tetms have been met. OUTSIDE CAF�S: Outside cafes(i.e,outdoor seating with waiter/waitress service),must have prior approval from the Board of Heatih. OUTDOOR COOI�NG: Outdoor cooldng,preparation,or dispiay 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 RESPONSIBILTTY TO RETURN TF�COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 16,2016. � ALL RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i:e., PAIIVTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T'HE BOARD OF HEALTH PRIOR I TO CO1vIl41ENCEMENT. RENOVATIONS MAY IRE I PL . ' DATE: l I�� ' SIGNATURE: � i��CL�C/��LL_ � � PRINT NAME&TTfLE: C.�� C.� I�N �CR l2R� pK.�S/D�(1,�I� �.iaivie i ' --�"�"� OP ID:KM '4�oRL'� CERTIFICATE OF LIABILITY INSURANCE ��MMIDDlYWY) 11/02/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THtS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEWD, EXTEND OR ALTER THE GOVERAGE AFFORDED BY TIiE PpLIC1ES BELOW. THIS CERTIFtCATE OF IN3URANCE OOES NOT CONSi'ITUTE A CONtRACT BETiNEEN THE ISSUING INSURER(S), AUTHORI2E0 REPRE$ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: 1f the certiflcate hotder is an ADDITIONAL INBURED,the policy(fes)must be endoned. If SUBROGATION IS WAIVED,subJeet to tbe tem�s and conditions of the policy,certaM policies mey require an endorsement A statement on this cert(flcate does not confer rights to the certlfieate holder in Ueu of such endoraemen s. VIflM.FcBorhek Insurance Agency PHo�Ec Fa 311 Plymouth Street n ac No: � Halifax,MA 02538 -Mai� Scott C Caaagrande AD�� c r� i •BECKE-1 INSURE S AFFORDINfi COVERA(iE NAIC N INSURED Seckers Package tore ,��R�A:Great American Ins.Co. 31 Polly Fisk Lane �NsuRea e:Massachusetts Retail Merchants Dennisport,MA 02639 INSURER C: INSURER D: 1NSURER E: 1 URER f• COVERAGES 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. NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIPI, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLIClES.LIMITS SHOWN MAY HAYE BEEN REDUCED BY PAlD C441MS. N3R iypE OF MISURANCE POLICY NUMBER PM�EFF Ip �P LIMITS OENERAL LtABIL1TY EACH OCCURRENCE S �,�� A X COMMERCiALGENERALLIABILIFY $PP 1SB51T8 10l21/2018 10121/2017 pREMISES Eaoccurtence $ 3QO,O CWMS-MADE a OCCUR MED EXP(Arry one person) $ �0,� X BusinessOwners PERSONAL&ADVINJURY S 'I,OOO,O GENERAIAGGREGATE S Z,O�� GEN'L AGGREGATE LIMIT APPItES PER: PROOUCTS-COMPKW AGG S Z,ODO,OO X pOLICY PRa LOC UQUOR S ��IMILJ�YM) i a AUTBMOBILE LfA81�ITY COMBINE�SINGI.E LIMIT a (Ea xddenq ' ANY AUTO —�–� BODILY INJURY(Per parson) S ALL OVYNED AUTOS BpDILY INJURY(Per xadeM) S SCHEDULED AUTOS PROPERTY DAMAfiE $ X HIRED AUTOS (PER ACCIDENT} X NON-OWNEp AUTOS S 8 UMBREt,LA LtAB p�CUR EACH OCCURRENGE E EXCESS L1A8 ��g�qpE AGGREGATE a DEDUCTIBLE s RETENTI N g ANW O EMPL CO�E P�B�� X WC STAT7- TR- OY Y/N .�l� B ANY PROPRIETORtYARTNER/EXECUTIVE 01�.�2�3� 01�1/2016 01/p1f2017 E,L EqCH ACCIDENT S ��0 OFflCER/MEMBEREXCLUDE�? ❑ N�A B (Ma�Mry in NH) RENEWAL ��/0�/2��7 01l01/2018 E.t.DISEASE-EA EMPLOYE S �� If y9s,descnbe wWer E.t.DISEASE-POIICY LIMIT a 500�� OESCRIPTION OF OPERATtONS below PROPERTY 110,0 STOrB LOCetlO�55 ROUt@ Z� W�Y ��tit�MA 026'y3��nal rtemuks schedule,it more apaee is reqWred) . , 81'fIIOU CERTIFICATE HOLDER CANCELLAtION TOWNYAR SHOUID ANY OF TME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTiCE Wii.l BE DELIVERED IN 7146 MAIN STREET.RTE.28 ACCORDANCE N11TH THE POIICY PROVISIONS. S.YARMOUTH,MA 02663 AU7HORIZEQ REPRESENTA7IVE Scott C Casagrande C�198&2009 ACORO CORPORATlON. All rights reserved. AGORD 25(2008/09) The ACORD name and logo are regiatered marks of ACORD