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Home My WebLink AboutApplication and WC Y--...-�.,.__.__........ . .._.:.....} r _ � TOWN OF YARMOUTH BOARD OF HEALTH i � APPLICATION FOR LICENSE/PERMIT-2017 1 'r;�f r ��V 5 *Please com lete form and attach all neces y ��'�'j� � � p sary documents b December l6 2 l6. , Failure to do so will result in the return of your applicahon pac et. ESTABLISHMENTNAME: �'K� •1 �c'•- � � �� f�:. LOCATION ADDRESS: D� '� a oW D�6 6'-/TEL.#: OS'-3`)t/�dg�� ;� MAILING ADDRESS: WI E-MAILADDRESS: OL . Ot.h OWNER NAME: CORPORATION NAME APPLICABLE): E ' d o��S Tt1C. Y� MANAGER'S NAME: 'f �� S T'EL.#: ^ ��//3 -=�� MAILING ADDRESS: . . eu '�f S �A lt �/ ' � � POOL CERTIFICATIONS: �s. r a,.---' 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 eopy of the certification to this form. �, 1. 2. � � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � Cazdiopulmonary 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 aad maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: Ail food service establishments are required to have at least one full-time employee whc is certified as a Food Protecrion 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 will not nse past years'records. You must provide new copies and maiutain a file at your establishment. t. �A,1�cI �� A t.S�1 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ' l. �A w�cS l ��n n� O 2._['�t2�c+w� 'L(I�A L-S I� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fuli-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Estabiishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicarion. Tbe Health Department will not use past years'records. You mnst provide new copies and maintain a file at your establishment. i. �w,arLc� J � w/4 LS� 2. 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 provid new copies and maintain a file at your place of business. 1. A �a s�►+�Arll 2. 3. ?Aw►t U�O(;�.�.d �v 4. "— RESTAURANT SEATING: TOTAL# �� P� �ST LI.C�,�S� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERM[T# B�B S55 CABIN $55 M01'EL $110 —INN SSS —CAMP S55 —SWIMMINGPOOLS110ea �,ODGE $55 ='I'RAILERPARK $105 _WHlRI,POOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PE T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-]00 SEAI'S 5125 ��'O�Z� CONTINENTAI, $35 NON-PROFIT S30 >100 SEATS $ZW �COMMON VIC. $60 � —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LYCENSF,REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 . >25,000 sq.ft. $285 VENDING-FOOD S25 _Q5,000 sq.ft. $150 �ROZEN DESSERT $40 �fOBACCO SI10 NnME c�rnxcE: S�s AMOUNT DUE _;� �� ,r�� '�_ � •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•+"• ADMINISTRA.TION 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 OR WORKER'S COMP.AFFIDAVIT SIGNED AND A'TTACHED Town of Yarmouth ta�ces and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENT`� TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be ]imited to the temporary and short term occupancy,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 shail 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 tlie 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 OPEr1ING:All switnming,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 pooi area uniil 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 Yannouth must notify the Yannouth 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 Heaith 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 ar�d 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 Boazd of Health. OUTDOOR COOKING: 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 RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,20I6. ALL RENOVATIONS TO ANY FOOD ESTABLISIIMENT, MOTEL OR POOL (i.e., PAINTING, NEW F.QUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: SIGNATURE: � /� l/D /1 (p PRINT NAME&TITLE: ��/ti c�►� 1/(��J �Al'/,��'f'G/" Rev.10A2/l6 / ' ; iui14i1016 12:33 Bryden and Sallivan Donna Seviour->Beth . 2I L. � �4CORU" PICCA-7 OP ID:QS - --�...- CER7IFIGATE �F LIABILI'Ty I(VSUR�NCE °�� T�CERT�FlCATE IS ISSUED AS A MATFEI�pF tNFORAAATION ONLY AND CONFERS NO RIGHTS UPON TyE CERTIFK;qTE HOL�.DER TyIS CERT�FlCATE DOES N07'AFFlRAAATIVELY OR NEGATIyF1,Y qN1ENq,p(TEND OR ALTHt THE COV£RA6E BEI.t3W. THIS CERTIFICqTE OF lNSURANCE ppES NOT CONSTIT'tJTE A<;pM'RACT g�Ep� T��pNG I�N�SU�RER(yy, qUTHORiZED REPRESENTp►TNEOR PRODUCER,AND THE CERTIFICA-I'E HOLDER. IMPORTANT: if the certif'x�e holder is an ADDITIONAL INSURED,the policy(ies)must be encorsed. if SUBROGATiON IS WANED,subject to the tetms and conditions of the policy,cerfain pol'rcies may requ've an ertdor� q�t�t on this certifica�e does nar oorff�rights to the • certiF'�cate hoider in lieu of such endo � � Bryden&Sul�ranMsAgency . �: HyaRnisOffice 88Falmoutl�$a�,d'�>, � r�:508-775-6060 _` ��R� rs•508-79Q-1414 � Hyannis ��,� aon�ss_ � �st,►�o�rovet� wu�s � Cape De}i Foods,lnc.dba �a:Guard�nsurancet3roup Piccadiliy Oeli BCafe �e= � _ 1lQSMainStreet �c: — South Ysrm outh,MA 02s64 �n: u�e: COVERAGES �� ` CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTiFY THAT THE POUCIES OF INSItRlWCE USTED BELOW HAVE gEEN �SSUED TO THE INSUREp IdAMEp qgpyE FOR THE POLICY PERiOD INDICATED. NOTiMTHSTANDING ANY RE(�1JiREMENT, TERM OR CONdITION OF ANY(ANTRACT OR OTNER pOCUMENT YttITH RESPECT TO WHICti THIS . CERIYF7CATE kiAY BE ISSUED OR IWAY FERTAIN, THE INSURANCE AFFORDED BY THE pOUCIES DE�RIBED HER4N i$SUB,IECT TO,4LL 7}�E TERbIS, �„,3 IXa�ONS AND CON�1T'lONS OF SUCH pOUCiES.LIMITS�i qlqY HAVE BEEN REDUCED BY PAtO CUUfiS. ��` L 7'YPE�W� �NL C'+�AL LJABW7'y �� L9�fi'S � �OCCUR ElYCFi 00C� S PREMISES Ea axut�rxe S A�0 E7�(MY ane Derson) ! ' , GENL AGGREGAiE LIMR APPLIES PER: PERSONAI.&ADV INJI,42Y $ . POLICY a�� LOC ��AC�REGJ47E g . ,� p�; �UCTS-�lOP AG� j AlJfGMOB1I.E LUieeJ'rY __ S ANY.4liT0 � �� 5 �O�YVPED ��Ep BODILY IN,RJRY(Per P�) S . �µpyy�gp BOOILY INJU2Y(Per ecddert} S FIIRED RUfOS y,lrps . S weae,u uas �� a occ�s uns cwMs�wo� �acr+o�.r.a� s o� �xna� s asc�r�,� s �� s vrH . sranne � A �DCa��E �NJA 1M1WCT6627T 081O�I201B O�/01IZO1T E.L.EACHA,ccIDHai . s �pp� ir��'�� EL O�SFASE-EA B�i�1.01'ff i $QQ, OF OPERA710NS belonr E.L.DISEASE-Pd.ICY UMIT $ �� . � I �i OF OPERA'IIONS f LOCATIONS J V6i(xES(ACORp 101.Ade�tia�al Rem�la Sdx�k,maY be akached�mor+e s�e is req�ro�y ertifieate issued for insurance verification. CERTIFICATE HOl.DER CANCELLATION YARM003 sFlOUID AN1f OF tHE A5G!!E�E9CRB�POL�ES BE CA�eEFatE THE EXP6lATION CIitTE 7'F�iEOF, NOTICE iMLL BE DgIVERED W. YARMOUTH TOWN HALL ��+7't�PouC�r PRov�, 1146 MAIN ST S.YARMOUTH,MA a2664 ^�"��'AT� Hyannis Offtce �1988-2014 ACORD CORPORATION. AII rigMs r�esenred, ACORD 25{2014J01) The ACORD name and logo are register�i marks of ArARD