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Home My WebLink AboutApplication and WC i ; TOWN OF YARMOUTH BOARD OF HEALTH { APPLICATION FOR LICENSEJPERMIT-2017 � � *Please complete form and attach all necessary documents by Decen�ber 16.2016. j Failure to do so will result in the retum of your applicauon pac et. � ESTABLISHMENT NAME: C Cv LOCATION ADDRESS: / OC�} V � �L_#: .. 6�� MAILING ADDRESS: E-MAIL ADDRESS:.�' L ry1 OWNER NAME: CORPORATION NAME APPLI LE): I✓I � MANAGER'S NAME:�/JL�/'11 � �L,#; 9 MAILING ADDRESS: O (�1/ POOL CER'TIFICATIONS: The pool supervisor must be certified as n Pool Operator,as required by State law. Piease list the designated Pooi Operator(s)anci attach a eopy of the certific�tion to this€orni. 1. 2, Pool operators must list a minunum of two employees currently certified in standard First Aid and Community Cardioputmonary Resuscitation(CPR),having one certified employee on premises at ali rimes. Please list the employees below and attach copies of their certifications to this Porm.The Health Department will not use paat yeara'records. You mn�t provide new copies and maiatAia a f51e at yoar place of b4sinesa l. 2. 3 4 , � < � FOOD PROTECTiON MANAGERS-CERTiFiCATTONS: � rv � All food service establishments are required to ttave at least one full-time emptoyee who is certified as a Food p � � Protection Mai�ager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. rn o '�'^s Ptease attach copies of certification to this applicarioa. The Aealth Department will not use past years'records. � --- � '� You muat provide new copies and maintain a fite at yoar establisshment. � � ��`i �.��5�`T �'1 e/�c1��J�y 2. ��Q y �I e l�2�'y , -- ' ______, PERSON IN CHARGE: �� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � i. ��1�%— /Y1��°/i� a. (1�1 d�� '� /11,t1��lf y_ s ; ALLERGEN CER'TIFICATIONS: k� "Y� � All food service establishments are requirefl to have at least one fiill-time employee who has Allergen certification, �" as defined in the State Sanitary Code for Food Service Establis}unents,105 CMR 590.049(G)(3xa). Please attach �` , � � ;i copies of certification to this application. The Health Department will not use past years resords. You mast � provide new copies and maintain a file At your establiahmenw �':>' � t `` �. ma��y m�,e�i�� 2.��(1 N� �� •• HEIIvILICH CERTIFTCATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list your employees trained in anti-chokwg procedures below and ' attach copies of employee eertifications to this€orm. The Heall�t DeparEmeut will not ase past years'records. ' You muet provide new capies and maiutain a fik at yoar place of buainesa. r. �O�IG�.� l� 2. /n0�-� /h �l�l�l�l�, 3. 4.-T RESTAURANT SEATING: TOTAL#_�_ - , i.oncnvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT�1 LICENSE REQUIRED FEE PERMIT� �9,8 S55 CABIN S55 MO'FEL SttO � SSS CAMP SSS =SWIMMING POOL S110es. �.ODGE S55 =TRAILERPARK 5105 `WHIRLPOOL S110ea FOOD SERVQICE: �Q-100 SEA1'SU�D 5125 ��Crp LIC�S��QUIRED �s PERMIT# L[CNON-PROFTf� S 0 PERMIT# >t00 SEATS 5200 V �COMMON VIC. $60 �Z �lVl;OLESALE $80 RETAIL 3ERVICE: —RESID.KTI'CHEN S80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' <50sq&. S50 >25,000sq ft. S285 VENDING-FpOD S25 � =<25,000 sq.R. 5150 � _F'ROZEN DESSERT S40 TQBACCfl St 1Q NAME CHANGE: S15 AMOITNT DUE _ $ ($5.QQ ; •`*•+PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'•+*• ��-F-l�F-632�-03 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 ATTAC�D STATE WORKER'S COMPENSATION INSURANCE I AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED � OR WORKER'S COMP'.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATEI,Y IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLiSHMENTS TRANSIENT OCCOPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy,ordinarily and cuskomarily associated with motel and hotel use. Tr�nsient occupants must have and be able to demonstrate ihat they rnaintain a princigal place of residence elsewhere.Transient ocxupancy 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 uttit as a residence ar dwelling unit shall not be considered transient. Occupancy that is subj�t to ttie collection of Raom Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient. POOLS POOL OPE1VIriG:All swimming,wading and wlrirl,pooIs which have been closed for the season must be inspected by the Health Department prior to opening. Cantact the Health Department to schedule t6e inspection three(3) days prfor to opening.PLEASE Nl�E:People are NOT allowed to sit in the pool area uutil the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,tatal coliform and standard plate count by a State certified 1ab,and submitted to the Heglth 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 FOQD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opeaing. Flease contact the Health Department to schedule the inspection three(3)days prior to opening. : CATERII�TG POLICY: Attyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requtred Tempo��aod Service Applieation form 72 hours prior to the catered event. These€orms can be obtamed at the H th Depazlment,or from the Town's website at www.vaimouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Frozen deaserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Depattment. Faiiure to do so wiIl result in the suspension or revocation of your Frozen ' Dessert Permit until the above terms have bPen me2. OUTSIDE CAF�S: ()utside cafes(i.e.,outdoor seating with waiter/waitr�ss service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor caoking,preparation,or display of any food product by a retail or food sc�rvice establishment is pro6ibited. NOTTCE:Pemnits run annualty from January 1 to December 31. IT IS YOUR RESPONSIBiLITY TO RETURN 1 THE COMPLET'ED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATiONS TO ANY F40D ESTABLISHMENT, MO"f'EL OR PO�L (i.e., PAINfING, NBW ' F.QUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY A S P DATE: ��!3'—/�� SIGNATURE: ; '/ �1 , PRINT NAME&TITLE: ..�.I D�1K� 1� US�J ,"- P /�yL�l Rev.t0712/16 : ! � ah t WlDdYYYY� �R� GERTIFlC�1TE C1F LlABILITY INSURANGE 11I22/16 THS CERIIFICAlE 6S l8StlED AS A MATTER OF MFORMA7MN1 OFt.Y ANl3 COMFERS NO aRICHTS U'C}N 7HE CERfiF1CATE HOLDER THS CER'f1FiCAlE DOES NQT AFFlRMA'fIVELY OR NEGATNELY AMB�D, EXTEI+D C1R AL7ER TFE COAIERA�tsE /RFFORDED 81f Tt� POLlGIES BEL.OW. 7HS CERTIRCATE QF INSURMICE DO� t�qT tANSTITliIE A C,ONTRA�T BETYYEEN Tt1E 1SSt�NG IN6t1RER�S .All�HOIiQED REPRESENTA7IVE OR PRODUGER.AND 7NE CE(illF�iCA7E HOLDER IMPORTANT: If the ceRilicale hal�r ia an ADDI INSURED,fie poiicy�i�s)must be endorsed. If SUBRO�A'I�N iS W ,aubjact to tl+e�srms ara1 eoncNtfons of the poNry,�Wlkles m�y requi�s an sndorsemsnt A atabmert on ttis ce�finEe t�s nd c i�r ri�tis b ltee �Aifleab holder in peu�such sMorawnen . �°� NAAE: R8 Travers �hagnon Insurance Agency, Inc. R"0� �08) 771-2660 R°x . � 08) 775-1135 PO Box 355 ra traversCeisinsu:=ance.net 611 Route 28 rNsow� s�wRar�cove��ce wac s West Yarmouth, I� �2673 �►WRHtA;Tlle Hartford In�urauzce ��► _ ._ _, �nee a:Fragdom S cial Iizs. Co. MAAM, InC. ��suRet c:MISGELI,ANE�J3 SURPLa73 LINE$- DBA Longfeiiows Pub ��p; e Har for - SCIC 530 Old Townhouse Road i��E:M23CE QUS SURPLtJS I.INES- � South Yarmouth, L+Il� 02 664 i �F, COVERACiES CERTIF�A7E N WMBER: REVI$�N NUMBER: T}iIS IS TO CERTIF`f THAT THE POI�ES OF{NSllFtANCE USTED BEL�MV FWVE BEEN ISSIJED TO T'h�INSl�2ED NAM�4BOVE FQR TH POLICY PFRIOD 1NDICATED. NOTYNTHSTAP�NG AHY RE4UIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPEC Tp WNICH THIS GERTFiCATE MAY BE iSSUED OR MAY PERTAN,THE INSIlRANGE AFFORDED BY TFE POLICIES DES{3tI�D HEREN 13 SUB,lECT TO THE TERMS, EX�CLUSiONS ANDCONDITIQNS OF SUQi POUCIES.LMfTS SHOVNJ IW1Y HAVE�EN REDUCED BY PAID CLANu1S. L7R - - TYPE��URANCE POULY � p� J LI�iS C �'�� NPPa382379 ifl/21116 1o/21li� �KpCCl1�ENCE 1 000 000 X ca�+eRcuucEr�w+��.iaeiuTv on►�v►c�rc r�nrrEo �,00 000 c�nn��aoe �occuR AIEO EJ�NMore �o�� 5 000 PERSO W4�S ADV IWURY 1 U00 000 GENERALA3GRfGATf 2 �QQ OQ� [,�li'l AGGREGJ\TE LMITAPPL�S�R PRODtfCTS-QOtaP1bP RGG 1, OOO OOO POLICY �� LOC AUT�DMOBN.E GJABItJTY Lf14 a atxicb�l f ANYAUW BOD�Y INJURY{Per pe�n} l4LL 0 WFE� SCHEDULED BOD�Y INJIJRY(Per ea:itlenty WTOS AUTOS HIREQAU79DS _�g�ED PRO�DAMAGE UiBRELLALUiB OCCUR FACHOCCIIf�RENCE EXGE38LiA6 ClA1MS�MADE AGG(�EGATE Dm REfENT1pN S a wOaueas cOMPEwBatx� 08 WSC CH9555 2/23i16 2123J17 X wc sraTu- OrH- AND 91W_OYERS UABILJTY ANYPROPRIETORfPARTNEWEl�CU7NE Y 1 N E.l.EACH fCCJ M lOO,OOO ' OFFICER�IEN�ER EXCLlDE47 � N(A P�II+rWbry fn NH) E.l.DISEASE-EA 6�FLOY IOQ OOO i � d��l1 OPERATIONSGeIOw EI.DISEASE-POUCYLM�! 50d dd� E Liauoz Liability 40Q894QiLL 1at191ie io/i911TOccurrence 300,000 Aqqretqate i bOfl.004 � CE8CRIP'fl�N OF OPERATIONS 1 L,�G710NS!V@iCLES(ll��ch AODRp�t.Addtlonr Re�rks SeAeduM.if mo►a spca k mw1 ndj T YQar round pub. tavern � Liquor Liability InCludad j i � i � i C�tTIFICATE HOLDER CANCELLATION SFIOULD ANY OF 71iE A80VE DESC WBED POliCEB HE CJ�IC�LED BEFORE THE EXPIRATION DAlE TIEREOF, NC�TtCE Wit,l 8E� QEUYfRED NI To�+r► Of YSi�Ot3th �bCdROANCE 1NIiM 1HE PQI.ICY PROYI3M�NS. ' R013'�A �B j 8. Yarmouth, MA 02664 "�TMO�D � � Kimberly E. qnon, G , CPIW � �1 �{t10 ACORD CORPORA?ION. ii�ghts resQrved. AICORQ 25{2010ta5) The 14C C1Rp e�ame and logo are req�tered marks of ACORD f Phone: Fax: E-MaiL•