The URL can be used to link to this page

Home My WebLink AboutApplication and WC �G ', TOWN OF YARMOUTS BOARD OF HEALTB G3 l�C�L�O�I C�DD : `: APPLICATIUN F4R LTCENSE/PERMPr-20 0 $?6 * Please complete form and attach all necessary docu�ientsr ecemL XS��O�.$ ��9 Faiaure to do so will result in the return of yaur:app�icat�c�n`pac . HEqL l H Utr�� . NAME OF ESTABLISHMENT: �, �M �_ (A �- 2Z-�o TEL. # So£��3��f 5�'�� LOCATION ADDRESS: d�! 1 �- r�L--� Sc� k'�r-�.a�`�...,� Ma- ��-(��`f MAILING ADDRESS:`��„n �� 1�G� S"o �,�,�--ma�� iV��, ��v�l OWNER NAME: T��ID fFEIN or S N��O�L�� K CORPORA.TION NAME (IF APPLICABLE): MANAGER'S NAME:„i v��► Sh�.��l=^ TEL. # S o43-'3 x Y��( MAILING ADDRESS: �t a�C3oK. �,£s� � Sa ::-ar�o-k�-.._.� �L �zCoC��( ��.w �.ri��w�w� �.n�.�.i PO4L 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 certificarion to this form. 1. _ _ _ 2• Pool operators must list a minimwm o£two employees currently certified in basic water safety,standard First Aid and Com�nunity Cardiapulmanary Resuscitation(CPR}. Please list these employees below and attach copies of employee certifications to this form. The Heatth Department will nat use past years' records. You must provide new copies and maintain a fde at yonr place of business. �. 2. 3. 4. FOOD PRbTECTION�VIANAGERS - 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 wiU not use pAst years'records. You must pravide new copies and maintaia a file at your establishment. 1. � ��zr� 2. PERSON IN CHARGE: __--- — -- -- __ _ _ Each food establishment must have at least one Perso� In C�arge(PIC)on srte c�urng�ours of operation. 1. ��n ,��r-t�2•-� 2. HEIMLICH CERTIFICATIONS: All food service establishments with 2S 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 anri-chakuxg procedures below and attach copies of employee certifications to this form. The Health Department will nat use past years' records. You must provide new copies and maintain a file at your place of business. 1.,,.��..��.� i(Y1,v r,�.�d 2. �(A n L� /��-2�,,.,�,�_— 3. �.,._< a t�.a,�, -S- 4: �F� Mon�f�� RESTAURA.NT SEATING: TOTAL# OFFICE US� UNLY LODGING: LIC�I�TSE REQUIRED FE� PERMIT# LICENSE REQUIRED FE$ PERMtT# LTCENS�REQUIRED FEE PERMIT# �BBcB $55 �, iCA$1N $55 _MOTEL $55 __,_IrIN $55 �,CAIvIP �55 _„_SWIIvI.MING POOL �80e�. _,LODGE $55 ^TRAILERPARK $105 lWHIRI.POOL $80ea. FOOD SERVICE: LICENS�REQUIltED FEE PERMIT# LIC�NSE REQUIRED �EE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SBATS $85 _,______�, �CONTINENTAI.. �35 LNON-PROFIT �30 �–46(0 >100 SEATS $160 �COMMON VIC. $b0 �WHOLESAL£ �80 RETAIL SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC£NSE REQUIRED FEE PERMTT# � V ND G-FOOD $25 ' <50 sq.ft. �50 >25,000 sq.8. �225 ` E 1N � -- � ,�d5,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO �55 x�cxaiv��: :$is AMOUNT DUE _ $ 3� .o0 wrwwwpLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**"** � � ADMINISTRATION t , : Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewaJ of any license or pernut to operate a business if a person or company does not have a CertiEtca.te of Worker's Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATION INSU1tANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED V OR WORKER'S COMP. AFFIDAVIT SIGNED ANv ATTACHED Town of Yarmouth taxes and liens must be paid prior tv renewal or issuance of your penmits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO z 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, ordinaril�and customarily associated with motel and hotel use. ; Transient occupants must have and be able to demonstrate that they ma.intain a principal place of residence elsewhere. ` Transient occupancy sha11 generally refer to continuous occupancy of nat 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 sha11 not be considered transient. Occupancy that is subject to the collection of Room Occupancy � Excise, as defned in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transierrtt. POOLS � � POUL OPENING:All swimming,wading and whirlpools which have been closed for the season must be ins by the Health Department�prior to opening. Contact the Health Departme�t to schedule the inspection three(� ; pnor to opening.PLEArSE NOTE:People aze NOT allowed to srt m the pool azea until the pool has been inspected and opened. � POUL WATER 1'ESTING: The water must be tested for pseudomanas,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 paol must be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify ths Yarmauth Health Department by Sling the wred Temporary Food Service Application form 72 hours prior to the catered event. These farms can be obtained t the Health Department. '. FROZEN DESSERTS: " Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension ar revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAF'ES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofHealth. OUTDOOR COOKING: Outdoor cooki�preparation,or display of an�foodproduct by a retail or food service establishmexrt is prohibited. ; NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPUNSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S}AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATTONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL. (i.e., PA,TI�TTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI�BOA.RD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � � ; DATE: /��(o � �' SIGNATURE: � f,� ----r— PRINT NAME&TITLE: v�e_r z� ,, � r— 09l25/09 h AG'�ORD,� CERTIFICATE OF LIABILITY INSURANCE 03-23AT2009 rao�ucen THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARS IL - MOOSE INTL/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5 5112 9 P: (8 6 6) 4 6 7-8 7 3 0 F: (7 04) 9 21-4 6 5 8 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 29611 CHARLOTTE NC 2 8 2 2 9 INSURERS AFFORDING COVERAGE p�SURED INSURERA:TWII1 C1t Fire IIIS CO INSURER B: #2 2 7 0 MOOSE LODGE INSURER C: PO BOX 1 H 6 �INSURER D: SOUTH YARMOUTH MA 02 6 64 INSURER E: COVERAGES 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 POIICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �pgp POLICY EPFECTIVE POLICY EXPIHATION UMITS �Tp TYPE OF INSURANCE POIICY NUMBER I DATE MM/DDIYY DATE MM/DOtYY GENEHAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABIIITY FIRE DAMAGE(Any ane firel $ CLAIMS MADE u OCCUR I MED EXP(Any one persoN� Si_, iPERSONAL&ADV INJURY S I GENERAL AGGREGATE I S GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG I S POLICY PRO- LOC JECT AUTOMOBILE LIA&LIIY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS IPer person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accidentl $ PROPERTY DAMAGE � IPer aecident) $ GAMGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S I AUTO ONLY: AGG S EXCESS LIABILITY EACH OCCURRENCE � S OCCUR u CLAIMS MADE IAGGREGATE S S DEDUCTIBLE S RETENTION 5 $ WORKERS COMPENSATION AND � X WC STATU- OTH- TORY LIMITS R A EMPLOVEBS'LIABILITY 8 3 WBG AY1016 0 5/O 1/0 9 0 5��1�1� E.L.EACH ACCIDENT SZ�� 0�� E.L.DISEASE-EA�MPEOV-EE $1 O O� O O O � E.L.DISEASE-POLICY LIMIT SS O O� O O O � OTHER DESCRIPTION OF OPERATiONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTlSPECIAL PROVISIONS 1 Those usual to the Insured' s Operations . �� CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION { SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE j EXP�RATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL Town Of Yarmouth 30 DAYS WRITTEN NOTICE(10 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE 1 Board Of Health HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 114 6 Rout e 2 H REPRESENTATIVES. ; South Yarmouth� � 02 6 64 qUTHOR D E�TNE �� ; ACORD 25-S (7/97) °ACORD CORPORATION 1988