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HomeMy WebLinkAboutApplication and WC .. .a � a ,., TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICEr���I� �2„ � ry �. k t� = ,: : ��°�' 'i�����6 * Please complete form and attach all nec�ssary docurner�ts;by� e mber 16 2016. Failure to do so will result in the�turn of your�app'� io ac �.p��� ESTABLISHMENT NAME: �,5' � TAX ID: LOCATION ADDRESS: � -�-e. � TEL.#: - ��-�" a-� MAILING ADDRESS: Gt r l� � ' E-MAILADDRESS: Q !c-bo No�6�q�� qQpsvC� ' OWNER NAME: ' � l.�c.r�S�S CORPORATION NAME (IF APPLI AB ): MANAGER'S NAME: ,�'C `�� �_�L ��Q. TEL.#: ��3-��.�.--.� MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated ' Pool Operatar(s) and attach a copy of the certification to this form. l. 2. 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 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.� V'C>�!� � a. � �a� .e� 2. __PERSON IN CHARGE:_-_- _—_r_ - ��_ - ^ _ _- ----- = - -- — 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 aintain a file at your establishment. 1. �L1L. -�. '' �c-'d 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 provide new copies and maintain a file at your place of business. ' 1. � l d� �Q `�G� r� � 2. 3. 4. �- RESTAURANT SEATING: TOTAL# � � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 IT1N $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 =TRAILERPARK $]OS _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 ��?—OZ( —CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 ��j � —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $2$5 VENDING-FOOD $25 <25,000 sq.ft. $I50 _FROZEN DESSERT $40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ `�S,QQ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i. :> ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal i 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 I 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 temparary 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 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. POOLS i 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 priar to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of � closing. I FOOD SERVICE ; E 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: �nyone who caters within the Town of Yarmouth must notify the Yarmouth 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 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 run 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 OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: SIGNATURE: � � , PRINT NAME & TITLE: f �� � � o Rev. 10/12/16 , i4`.,�",,,,Vi rV� CERTIFICATE OF LIABILITY INSURANCE °a'Ec""�°°"Y°n 11/17%2016 THIS CERTIFICATE IS ISSUED AS A AAATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ! CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVE�Y AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES j 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 certfficate holder Is an ADDRIONAL INSURED,the polky(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certaln policles may require an endorsement A statement on this certificate does not coMer rights to the ' certiflcate holder In Ileu of such endorsemen s. I BPryd n&Sullivan Ins Agency �EACT H annis Office � 88 Falmouth Road �ONE •508-775-6060 F� No:508-790-1414 ; Nyannis,MA 02601 e-Ma� Hyannis Of(iCe AD°R�0 INSURER S AFFORDING COVERAGE NAIC� INSUHER A:TFt@ H81'�OIY� ��7 IN�RED Inaho-Japanese Restaurant INSURER 8: 157 Route 6a Yarmouthport,MA 02675 INSURER C: INSURER D: INSURER E: INSURER P• COVERAGES CERTIFICATE NUMBER: REYISION 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. �7p TYPE OF INSURANCE pOLICY NUNIBER M �Y� ��Y�P LIMRS COMMERCUIL GENERAI W►BILRY EACH OCCURRENCE $ CLAIMSauIADE �OCCUR PREMISES Ea occurrence $ MED EXP(My one person) $ PERSONAL 8 ADV INJURY $ GEN'l AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOIIAOBII.E LWBILRY COMBINED SINGLE LIMIT $ Ea accidert ANY AUTO BODILY INJURY(Per person) $ A�OOSNMED SACUTHOESULED BODILY INJURY(Per accideM) $ NON-0WNED PROPERTYUAMA E HIRED AUTOS pUTOS Per accident $ $ UMBRELLA W1B OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION ER O - ANDEMPLOYEflS'WIBILITY Y�N STAME ER A ANY PROPRIETOR/PARTNEWEXECUTIVE OBWECISS465 O$IO?JEO16 O$�IOT./Z017 E.L.EACH ACCIDENT $ 'IOO� OFFICER/MEMBEREXCLUDED? ❑N/A (Marwlatory In NIQ E.L.DISEASE-EA EMPLOYE S 1aI, iFyes,desaibe under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ SOO� DESCRIPTION OF OPERA710NS/LOCA710NS/VEHICLES(ACORD 101,Additional Remarke Schedule,may be anached H more space ia req4ired) Certificate issued for insurance verification CERTIFICATE HOLDER CANCELLATION YARM003 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTIGE WILL BE DELNERED IN YARMOUTH TOWN MALL ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN ST S.YARMOUTH, MA 02664 AU7'HORQED REPRESENTAi1VE Hyannis Office O 1988-2014 ACORD CORPORATION. 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