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Home My WebLink AboutApplication and WC� i :.�. TOWN OF YARMOiJTH BOARD OF HEALTH APPLICATION FOR LICENSFJPERMIT-2017 *Piease complete form and attach all necessary documents by Dece�n r 16 2016. Failure to do so will resutt in the retum of your applicahon pa �et. ESTABLIST�IIvIENT NAME: • o- 0 LOCATION ADDRESS: T'EL.#: — ' (�S� MAILING ADDRESS: r� � 1 �• E-MAII,ADDRESS:�1 ��A��n n � ` �� OWNER NAME: � R -� ' CORPORATION NAME(IF APPLICABLE): " ?R � _\`�, ; MANAGER'S NAME: � H �� TEL.#: "'� ' p, � MAILING ADDRESS: i POOL CERTIFTCATIONS: � The pool superviaar mnst be certiRed as a Pool Operator,as requind by State law. Please list the designated ; Pool Operator(s)and att�ch a copy of the certification to this form. � 1. /� 2. / = Z � I Pool operators must list a minimum of two employees currendy certified in standard First Aid and Community � � �"� Cardiopulmonary Resuscitation(CPR),having one cedified employee on premises at all times. Please list the � +v C°'� employees below and attach copies of their certifications to this form.The Health Department will aot use past � yeara'records. Yom m�st provide new copies and maintain a file at your plxce of basinesa � N '�Q� i. 2. m� o �"�E� �i 3. 4. -1 0� �� FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one fuil-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. �y,: Please attach copies of certification to ttris application. The Health Department will not use past years'records. You must provide new copies and mnintain a Sle at yonr establishment. ui `� I. 2. PERSON IN CHARGE: `�,�"��'� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. r�° ��':� � '�'� ALLERGEN CERTIFICATIONS: �+�^�P��"'� AIl 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)(3xa). Please attach - copies of certification to this application. The Heslth Department will not use past years'recorda. You mnst provide new copies nnd m�intain a file at your establishment. 1. 2. p 0 HEIMLICH CERTTFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich � Maneuver on the premises at ail times. Please list your employees irained in anti-choking procedures below and �" attach copies of employee certific�tions to this form. The Health Department will not use past years'records. � Yoa mast provide new copie�and maintain a fik At yonr place of business. � 1. 2. � 3. 4. � RESTAURANT SEATIl�TG: TOTAL# �d W OFFICE USE ONLY LODCIIVG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT# H�B S55 CABIN S55 MOTEL S110 —INN S55 CAMP S55 =SWIMWIING POOL St l0ea. �.ODGE S55 =1RNLERPARK 5105 _WHIRLPOOL SllOea FOOD SERVICE• LICENSEI�Q UlREp FEE ERM[P M LICENSE REQUIRED FEE PERMiT# LICENSE RE(jU[RED FEE PERMlT# �0-100 SEA7'S S125�(?�032. CONTlNENTAL S35 NON-PROFIT S30 >ioosEnnrs szoo �co�oxvic. sso �2! —wxo�s,� sao RS7'AII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# <SOsq ft. S50 >25,000sq B 5285 VENDING-FOOD S25 =Q5,000 sq.ft. SISO �ROZEN DESSERT S40 TOBACCO Sll0 NAMECHANGE: S15 AMOUNTDUE = S IS5•OO ••'**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*+�++ T r ADMINISTRATION Under Chapter 152,S�tion 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 dces not have a Certificate of Worker's � Compensation Insurance. '1`AE ATTACHED STA7'E WORKER'S COMPENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED,OR j � � CERT.OF INSURANCE ATTACHED I �R iWORKER'S COMP.AFFIDAVIT SIGNED AND ATTACI-IED � 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 ESTABLISIiMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,TrazLsient occupancy shall be limited 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 eisewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of nof more than ninety(90)days witivn 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 OPENING:All swimming,wading and whirlpools wlrich have been closed for the season must be inspected by the Health Departmentpn or to open�ng Contact the Health De�rtm ent to schedute the inep�c�on t6ree(3) days prior to opening.PLEASE NOTE:P�ple 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 quartetly 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 Departrnent prior to opening. Please contact the Health Department to schedule the inspechon 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 Tempo Food Service Application form 72 hours prior to the catered event These forms can be obYamed at the H�th Department,or from the Town's website at www.varmouth.ma.us tmder Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thercaRer,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pern�it until the above terms have been me� OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiterJwaitress service);must have prior approval from the Board of Health. OUTDOOR COOKIi�TG: 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.TT IS YOUR RESPONSI$ILITI'TO RET'LJRN Tf�COMPLETED RENEWAL APPLICATI�N(S)AND REQUIItED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINT7NG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS Y REQUIRE A STI'E P DATE:��- �- � (n SIGNATURE�:��. L� PRINT NAME&TITLE:V Y\�Q�� .S�Xt� " �1 o�n a� Rev.IDl12/16 . � � � J .4Co� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) �..►� 03/28/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 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 certificate holder is an ADDITIONAL INSURED,the policy�ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the tertns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). � PRODUCER ONTACT ', GermaniInsurance Agency PHONE FAx 908 Main Street ac No ex[: 508 428-9194 ac No: 508 428-3068 { Osterville,MA 02655 ADD�SS:certs ermaniinsurance.com � INSURER�S)AFFORDING COVERAGE NAIC# iNsur�R n;Main St.America Assurance Co. INSURED INSURER B: The Grump Inc.D/B/A Sweet Tomatoes Piaa INSURER C: 170 Hollingsworth Rd. � Osterville,MA02655 wsuReR�:NGM(National Grange Mutual) ' INSURER E: I INSURER 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. 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 7ypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MMIDDIYYYY LIMiTS A X COMMERCIAL GENERAL LIABILITY BPT4921R 3/4/2016 3/4/2017 EACH OCCURRENCE $ 1,000 000 DAMAGE TO RENTED CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence $ A X Liquor Liabilitv BPT4921R 3/4/2016 3/4/2017 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ ' GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $ 2,000,000 ; POLICY❑JE C � ��C PRODUCTS-COMP/OP AGG $ 2,000,000 � OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ i Ea accident ! ANYAUTO BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS � � NON-ONMED PROPERTY DAMAGE � HIRED AUTOS AUTOS Per accident $ $ A X UMBRELLA LIAB OCCUR CUT0488N 3/4/2016 3/4/2017 EACH OCCURRENCE $ 2,000,000 . EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2 000 000 DED RETENTION$ g D WORKERS COMPENSA710N WCT0488N 3/4/2016 3/4/2017 PER OTH- AND EMPLOYERS'LIABILIiY Y�N STATUTE ' ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ SOO,OOO OFFICER/MEMBER EXCLUDED? � N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPER,4TIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCWPTION OF OPERATIONS/LOCA710NS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be altached H more space is requiretl) loc 1: 461 Station Ave.,Bass River,MA 02664-1849 Loc 2: 790 Main St.,Chatham,MA 02633-1823 *Merril�Sweet is excluded. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouti� THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 026644492 AUTHORIZED REPRESENTATIVE �- �-- O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD