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Home My WebLink AboutApplications and WC��i • � � �0��-�+4-0�6-03� � �� '1"�ve��'',� i ( � �, � � + TOWN OF YARMOUTH BOARD OF HEALTH ��'� � APPLICATION FOR LICENSE I'��2017 N�y ?��16 , � � `°' * Please complete form and attach all necessa ""> � �b'y�ec ber 16 2DI b. Failure to do so will result in the ret f yo�application ck�t�A�TH �E�T. ESTABLISHMENT NAME: r TAX ID: - ' LOCATION ADDRES • 31 Wlcl�►�1 ��" TEL.#: S� '�Q ' 3u > MAILING ADDRESS: ' + G� 3 � E-MAIL ADDRESS:�a�,h u� (J G.o I. � pY"1 OWNER NAME: CORPORATION NAME (IF APPLICABLE): I�'1 Gl�d1 s� 7`� 1' L L � MANAGER'S NAME: {'1 G � ({G �� TEL.#: - � 3 MAILING ADDRESS: P � ��- �/M Vl'1 t- POOL 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 certification to this form. - -- 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. 11nic ��z� �G►�-e Z. L�w�c� �rydre� PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. a � l. n'1�C,�a� I ��A�� 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 maintain a file at your establishment. 1. t��Ch��I I�� n-�e 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� C.VIf�1 � ��G � � 2. 3. 4. i RESTAUR.ANT SEATING: TOTAL# OFFICE USE ONLY L nnGT1�L• — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: L]CENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 �� CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 a�'�-�'�Zcf _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � <25,000 sq.ft. $150 =FROZEN DESSERT $40 TOBACCO $I 10 i — — NAMECHANGE: $is AMOUNTDUE _ $ ISS.00 **�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � , "�—� � ,� f � . � ADMINISTRATION - j 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 1NSURANCE ATTACHED i 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 OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 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 � 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 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. i _ s FOOI) 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 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: i 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. ._ ; i � NOTICE:Permits ruY 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� UIRE A SITE PLAN. DATE: rJ'��'l(� SIGNATURE: � / " � `" � PRINT NAME • SG� r�. D 6 �c,►� f� Vl � r ci� � � ; ; & T'ITLE. � � � ,�—�� Rev. 10/12/16 i 4 ! � 4 3 .�� SKP1M-1 OP ID:AAK '`��R�''� CERTIFICATE Of LIABILITY INSURANCE `��`""'°°"�"Y' 09/23/2016 THIS CERTIFlCATE IS 133UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO W<3HT3 UPON 7HE CERTIFICATE HOLDER.THIS CERTIFICATE DQES NOT AFFIRMATNELY OR NEGATIVE�Y AMEND, EXTEND OR ALT€R THE CONERAG� AFFORDED BY THE PO�ICIFS ' BELOW. THIS CERTIFtCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETYYEEN THE ISSUING INSURER{S), AUTHORIZED ' REPRE3ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLQER. IMPORTANT: If U�s certi8cate hofder is an AQDITIONAL INSURED,the poltcy(�s)m�t be endorsed. If SUBitOG/4TION IS WAIVEA,subject to N�e tertns and condi8a�s of the polky,cehain policies may requfre an endorsement. A stabement an this certH9cate do�not coMe�rights to the cert'dicate holder in lieu of such e s. ��R ,,,�; DGP-Miles Insurance A ,inc. DGP-Miles lr�urance A�encY,ltu .5Q8-824-8961 �No 508-880-27'34 3 School Street P.O.Box 1�1$ ; TauMon,MA OZ780�0957 ��; G�don G.Asack s n�vx�c c� wuc� " �A:Technol {ns.Co. AMTRUST �sur�o SKP1M,LLC dba Skippy's Pier 1 p,��s; ' 731 Main Street�U.C-dba Tavem 731, 277 S.Shore Dr, ��c: LLC dba Surf&Sand Matet p��p; Sandra Di Ciiovanni P.O.BOX 370 NiSURER E: S Y8ff110t1�1 MA OZB� WBURER F: COYERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TFV1T THE POUqE3 OF INSURANCE USTE�9ELOW W1NE BEEN ISSUED TO THE IN3URED NAMED ABOVE FOR THE POI,ICY PERIOD i INOICATED. NOTWITHSTANDNJC,ANY REQUIREMENT, TERM OR GONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH RESPECT TO WHiCH THIS j CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFQROED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO All THE TERMS, � EXClUS10N3 AND CONDITIONS OF SUCH POLICI£S.LIMITS SHOWN MAY 11AVE BEEN REDUCE�BY PAID CtA1MS. I TR ?YP�E OF M1SURAlICE POLICY Nu118ER LNOTS ��'�� EACH OCCUF�tENCE S , COMMERCIAL CEt�RAl.LIABILITY g S j CtAl1�AS-MADE �OCCUR t�D EXP a�e aon) S , PERSONAL 8 ADY INJURY S QENERAI ACiGREGATE S GEML AC3GREGATE LWNT APPLIES PER: PROaI)CTS-CWY��P AGG S POLICY �� I.00 i AU7�E UABNIIY Ea acdOrM � S ANY AUTO 80011Y INJURY tPor Puaon) S ��° a�° eookr�Rr��«,�ocwsm� a r�o,unos "n�°r�D s s UM�LL/I UA8 OCCUR EACH OCQIAtRENCE t EXCESS L4t8 CLA�rAAADE AGGREGATE S RETENTION S S 1MOwCERS OdIWENBATWN WC STAN- OTH- AND E1IPLOYERS'LJABN.ITY A ANY PROPRIETORIPARTI�RlEXECUTNE Y/N C3649265 06J29/2016 051Z8/2017 ��c�wr s 1Q0, OFFICERlM�M�ER EXCLt�EDt � N/A ��yes� �� E.l.OlSEASE-EA EN�L S �� DESCRiPTqN OF OPERATiQP►S botow E.l.DISEASE-POLICY UMR i �� 1 OF OPERATIONS!IOCAT10N8/VEii1CLEB�Athelt ACORD 101�Ad�BonN Ramufcs 9tl�Nde,H awra ap�cs Is requNMJ CERTIFICATE HOLDER TION YARMOUT SF�D AlIY OF TF�ABOVE DESCRIBED POIICiE3 BE CANCELLED BEFARE Town of Yarma�th THE EXPIRATION DATE THEREOF, NOiiCE WIIL BE DELIVERED IN ACCORDANCE YYtTit THE POI.ICY PROVISIONS. Town Hall Yamouth,MA �� l�aR.L..,.�` \ U �1986-x010 ACORD GORPORATION. All rigMs reserved. ACpRD 25(2010/OS) The ACORD name and bgo are reg�sbered marks of ACQRD