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Home My WebLink AboutApplication and WC, , ; v ` � - � TOWN OF YARMOUTH BOARD OF HEALTH ��° - Y,"� � � APPLICATION FOR LICEN � � '20�'� � pEC i > ?_Q16 '�`� � � �, `'�� * Please complete form and attach all nec �` d rne�t�� }'e ber 16 2016. Failure to do so will result in the r : ` o " �►a�r n p cke�#��._T;- ! _,; ' ESTABLISHMENT NAME: � —' � TAX ID: - LOCATION ADDRESS: � TEL.#: ' MAILING ADDRESS: E-MAIL ADDRESS: ��,�.�S�rts-�a'�� , �a,n,-, OWNERNAME: � VG.tf1C1-P..(� �. Z.Gt.im, 1,�1'c S CORPORATION NAME (IF APPLICABLE):(��a�'Y1C,r; �1�r�CG, MANAGER'S NAME:`�� Yl t n ,(�-r� TEL.#�t�-7 7 J -7�7 7� MAILING ADDRESS: J_�ct m�— 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. 1. 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 d maintain a file at your establishment. � � 1. a�hi�Mw� �J'�t'�D 2. �F�. �1�- �rY�dt9.1 PERSON IN CHARGE: Each stablishment must hav t least one Person In Charge (PIC) on site during hours of operation. 1. ` .Jt�' 2._��C�C�_ L_-�.�� 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 an�l maintain a �le at your establishment. � 1.�/�� Y Y� 2. �' Yl 1' �5� ��'Ll.ii'l�l��(A� 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. �� A 1. Y ►�� 2. �V��"i.�i►G�. �,t"Yl r.�`�— 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 I� $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQtiIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENT.AL $35 NON-PROFIT $30 T>100 SEATS $200 �.�T�-'� �COMMON V;C. $60 ��j� =WHOLESALE $80 RETAIL SE CE: —RESID.KITCHEN $80 �� cEQUIRED 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 _FIZOZEN DESSERT $40 =TOBACCO $ll0 NAME CHANGE: $15 AMOUNT DUE _ $ Z�O,.� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** -- , ADMINISTRATION 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 OR . WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pertnits. 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 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 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 TE�TING: 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. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Deparhnent 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 obtamed at the Health Department,or from the Town's website at www.varmouth.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 AN P ROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY QU A SITE PLAN. ' DATE: ��,�� SIGNATURE: ; PRINT NAME & TITLE: � W�� - Y V`'` Rev. 10/12/16 Client#:22600 2DIPARMA ACORD,M CERTIFICATE OF LIABILITY INSURANCE D 70/12/2016 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 terms 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 NTA T NAME: Dowling&O'Neil Insurance Ag ��"N E,�,508 775-1620 ac No: 5087787218 973 lyannough Rd,PO Box 1990 E-MAIL Hyannis,MA 02607 ADDRESS: 508 775-1620 INSURER(S)AFPORDING COVERAGE NAIC# iNsuReRa:Guard Insurance Group INSURED INSURER B: Calamari,Inc DBA DiParma Italian Table A/O Tasty Tidbits Realty Trust �NSURER C: 175 Main Street INSURERD: West Yarmouth,MA 02673 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. 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 CIAIMS. INSR TypE OP INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IN R NND POLICY NUMBER MMIDD MM/DDMfYY A GENERAL LIABILITY CABP748941 6/15/2016 06/151201 EACH OCCURRENCE s 1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES EaEoNccTuE ence SSO OOO CLAIMS-MADE �OCCUR MED EXP(Any one person) $�J��0 PERSONAL R ADV INJURY $� OOO OOO GENERALAGGREGATE $2 OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $��OOO�OOO POLICY �E� LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-0WNED Peraccident $ HIREDAUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERSCOMPENSATION CAWC773435 6/01/2016 06/01/201 X �STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORlPARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $SOO OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $SOO OOO If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO OOO A Liquor Liability CABP748941 6/15/2016 06/75/201 $1,000,000 per occ $2,000,000 aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Addltional Remarks Schedule,ff more space Is requlred) insurance coverage is limited to the terms,conditions,exclusions,other timitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions.Members are included under the workers compensation policy. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORRED REPRESENTATIVE �� c� O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORO #5778052/M178051 LS1