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Home My WebLink AboutApplication and WC, ' ' TOWN OF YARMOUTH BOARD t?F HEALTH ,Y� � '+ APPLICATION FOR LICENSE/PERMIT-2017 - *Please complete form and attach all necessary documents by cembe•I6 2016. Failure to do so will result in the return of your applicaUon pac et ESTABLISHMENT NAME: S LOCATION ADDRESS: �1�t� f TEL.#: v 3 C� MAILING ADDRESS: k �v� E-MAII.ADDRESS: ' ► yS 1� c.1� t_u� � ' OWNERNAME• o.•tt�C' � i `S CORPORATION NAME(IF APPLICABLE):�"�t,rn�� /� . L t �t T�u c.. MANAGER'SNAME: l,,v t'� TEL.#: — 7��f— �/�7-/C7Y � MAILING ADDRESS: 1�I 3r-�.r��e-c� ac.c� �ItJ /�7- 3 S POOL CERTIFICATIONS: The pool snpervisor mnst 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 ttus form. L 2. I �' Pool operators must list a minimum of two employees currenfly certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the S ..�, ' employees below and attach copies of their certifications to this form.The Health Department will not ase past �rt �-�j � years'records. You must provide new copies and maintain a file at your place of business. � -C � I ,FA i .1. 2. . T��' ►V ��."i � � 3. 4. N ' n a � ' --1 rn FOOD PROTECTION MANAGERS-CERTIFTCATIONS: "� All food service esCabiishments 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. Ptease attach copies of certification to this application. TLe Health Department will not use past years'records. You must provide new copies and maintaia a file at yonr establishment. 1 � f N�J 2 �.�"�.� ,� � PERSON IN CHARGE: �.•':_ � 4 Each food establishment must have at least one Person Tn Charge(PIC)on site during hours of operation. � z��; ,r� � �'t �* sv l. �:C� �--[.Z.iw�.Y.�C�CU:J�i.►� 2. c'TCUPI`� J y.!MM�[' � �.. : ALLERGEN CERTIFTCATIONS: �� , 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 ��z �Y°; copies of certification to this applicarion. The Health Department will not use past years'records. You must provide new copies and maintain a file at yonr establishment. i. �J � rc,,f-yv�✓ 2. HEIMLICH CERTIFICATIONS: � i All food service establishments with 25 seats or more must have at least one employee trained'u►the Heimlich � Maneuver on the premises at ail times. Please list your employees trained in anti-chokwg procedures below and � attach copies of employee certifications to this form. The Health Degartment will not use past years'reeords. You must provide new copies and maintain a file at yoar place of business. ' � t._ �,. 2 t. .��-�u. L o-Z�� 2. A 3. 4. ,_NC. � RESTAURANT SEATING: TOTAL# �' N OFF'ICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTC# LICENSE REQUIRED FEE PERMIT# �B S55 CABIN S55 M07'EI. 5110 —'� S55 '�CAMP SSS —SWIMhIING POOL SI IOea �ODGE S55 _T'RAILERPARK 5105 _VVI-IIRLPOOL $IlOea FOOD SERVICE: LiCENSE REQUIILED £EE LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMtT# �0-100 SEATS $125 q��,�j CONTiNENTqI, S35 NON-PROFIT $30 ?100 SEAT'S 5200 �COMMON VIC. S60 �� —'WFIOi.RSAi.F $$0 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT N �5�sq ft. S50 >25,000sq R S285 VENDING-FOOD S25 =QS,OOOsq.R SISO � =FROZENDESSERT $t0 =TOBACCO 5110 NAME CHANGE: S15 AMOUNT DUE = S E$�.� ': ""*'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'•"•* r i c , � 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. 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 raust be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPR6PRIATELY 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 temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able fo demonstrate that they maintain a principal place of residence eisewhere.Transient occupancy shali generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days wi#hin any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered uansient. 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 OPEIVING: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 epartment to schedule the inspection three(3) days prior to opening.PLEASE NOTF:People ate NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and stsndard plate count by a State certified lab, and submitted to the Hea1th Depariment 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 SEASON.AL FOOD SERVICE OPENING: All food service establishments must be inspected by the Heaith Deparnnent prior to opening. Please contact the Health Deparhnent to schedule the inspection three(3)days prior to opening. i CATERING POLICY: j Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the J required Temporary Food Service ApplicaGon form 72 hours prior to the catered event These forms can be � obtained at the Health Depart�►ent,or from the Town's website at www.yanmouth.ma.us under Health Department, , Downloadable Fornns. FRUZEN 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. OUT'SIDE 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 proLibited. NOTICE:Permits run annually from January 1 to December 31. Tf LS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATTON(S)AND REQLIIKED FEE(S)BY DECEMBER 16,2016. ALL RENO�ATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW ' EQUIPMENf,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRiOR + TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A STI'E PLAN. DATE: t� �.'L�l�G� SIGNATURE: � �� PRIlVT NAME&TTTLE: �1 �/v�e.l' /t. L��i d+.cl,�:tt— ' I � Rev.10/12/16 ' :�1 ati<ii�v.v vi,L.� ...J...w. uuu ............ ..w„w .......vu, u..ui..aa w a.a....u.�aaa �j LC}/{,. 1/1 •/� JAMES-2 OP ID: DS i aco�zo� CERTIFICATE OF LIABILITY INSURANCE °A'�`M"�°°'""�" � `'� 11/29/2016 � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY 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 certificate holder is an ADDITIONAL INSURED,the policy(ies)must he endorsed. If SUBROGATION IS WAIVED, subject to { the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confe�rights to the certificate holder in lieu of such endorsement s. PRODUCER � CONTACT ; Bryden&Sullivan InsAgency �oNE Hyannis OffiCe A 88 Falmouth Road �uc No exc:$08-775-6060 �,,,�c,N,>:508-790-1414 � Hyannis,MA02601 ADD�ss: Hyannis Office INSURER(S)AFFOR�ING COVERAGE NAIC i wsu�Rn:The Hartford 22357 � �rvsu�o James A.Liadis,Inc.DBA �r,suReRe:MountVernon Fire Ins Co B i ack Sh eep Bah 8 G ri I I INSURER C: 84 Rocky Ridge Road Den n i s, MA 02638 INSURER D: INSURER E: 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. N07WITHSTANDING 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 T0 ALL THE TERMS, 1 EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �� TYPE OF INSURANCE � INSD POLICYNUMBER MMl�DMlYY MMlDD/WW LIMITS COMMERCIAL GENERAL LIABILIN EACH OCCURRENCE $ i CLAIMS-MADE �QCCUR PREMISES(Ea occurrence) $ MEG EXP(Any one person) $ PERSONAL&ADV INJURY $ . GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ � POLICY �jEa �LOC PRODUCTS-COMP/OP AGG $ GTHER: S AUTOMOBILE LIABILITY . - COMBINED SINGLE LIMIT $ _ (Ea accident) ANY AlITO BODILY INJURY(Per person) $ i ALL OWNED SCHEDULED BODILY INJURY(Per accident $ j AUTOS AUTOS � � HIRED AUTOS A�pSWNED OP TY AMA $ � (Per accident) $ i � UMBRELLA LIAB OCCUR EACH OCCURRENCE $ � EXCESS LIAB qp,IMS-MADE AGGREGATE .$ DED REfENTION $ $ i WORKERS COMPENSATION PER OTH- i AND EMPLOYERS'LIAB�LRY STATUTE ER A 0 FICEwME BE exC UD D�CUnVE Y�N/A 08WECCI6466 03/08/2016 03/08/2017 E.L.e,aCHACCIDEnrr $ 500,000 (Mandatory in NH) E.L.DISEASE-c4 EMPLOYEE $ 5�0,�0� � If yes,descnbe under DESCRIPTION OF OPERP.TIONS below E.L.DISEASE-POLICY LIMIT $ SOO,QO B Liquor Liability CL2636971C 02/25I2016 02/25/2017 DESCR1PT1pN OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 107,Additional Remarks Schedule,may be attached if more space is required) Restaurant: Liquor Liability I i m its as follows: $1000K Per Person $1000K PerAccident $2000K Aggregate CERTIFICATE HOLDER CANCELLATION YARM008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN YARMOUTH TOWN HALL ACCORDANCE WITH THE POLICY PROVISIONS. Health 8�Licensing Dept. Au�oR�o�aaesernarnE 1146 MAIN STREET Hyannis Office S.YARMOUTH,MA 02664 O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD