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Home My WebLink AboutApplication and WC -� d TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE/PERMIT-2017 `� *Please complete form and attach all necessary documents by December 16 2016. Failure to do so will resWt in the return of your appiication pac et. ESTABLISHMENT NAME: � � -C9 1 LOCATION ADDRESS: Ea�`� �n�i'T C �L$'_(►�,YAR.McT�I,'C K TEL.#:.�6�s 7�.4-'03Q4 MAILING ADDRESS: P V Fs� �{d 3� Z_�(A M�c�.�('El y t✓� O Z.t.LtiC ' E-MAIL ADDRESS: OWNER NAME: CORPORATION NAME(IF APPLICABLE): rN s c i U' MANAGER'S NAME: A C 1 L� I C O TEL.#: MAILING ADDRESS: u� � POOL CERTIFICATTONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and aitach a copy of the certification to this form. 1. F' � �-x,.....a�_�,.�__n._.� 2' � i Pooi operators must list a minimum of two employees currently certified in standard First Aid and Community ,' p Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all rimes. Please list the � employees below and attach copies of their certifications to this form.The Health Department will aot use past , years'records. You must provide new copies and maintain a file at your place of business. i::: --+6 1. � � 2. ; rv : 3. 4. � � L.:; rn E 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 fbr Food Service Establishments, 105 CMR 590.000. �:' �� Please attach copies of certification to this application. The FIealth Department will not use past years'records. e '` � ' You must provide new copies and maintain a file at your establishment. � � '� 1. 5�� 2' PERSON IN CHARGE: �,-. , � _ Each f d establishme ust have at least one Person In Charge(PIC)on site during hours of operation. �'" � 1. 4- �'�✓�/'LU�� 2. w ; v�r 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 CNIR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Departg►ent will not use past years'records. You raust _ provide w co�i a d maintain a file at your establishment. , � - 1. 2. - HEIMLICH CERTIFICATTONS: 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 empioyees 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. f',��///;�� i�-�il/a�lL/ 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PF.RMIT# BBcB $55 CABIN $55 MOTEL $110 INN S55 —CAMP S55 _SWIMMING POOL S110ea _LODGE a55 _TRAILERPARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS a125 CONTINENTAL $35 NON-PROFIT $30 =>100 SEATS 5200 �!j �COMMON VIC. $60 �� _WHOLESALE $80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# <5 sq. 50 >25,000sq�ft. $285 VENDING-FOOD $25 —<25,000 sq.ft. 5150 _FROZEN DESSERT S40 =TOBACCO $110 NAME CHANGE: S15 AMOUNT DUE _ $ 260.OO **•*•PLEASE TURN OVER AND COMPLETE OTIiER SIDE OF FORM*•*•• a 6��.-o�Lq-Q3 � r ' ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insarance. 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 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 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 TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a Siate 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 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 reqwred 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 Departrnent, 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 waiterlwaitress 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 establislzment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETCTRN 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 REPORTE ND APPROV BY THE BOARD OF HEALTH PRIOR TO COMMENCE NT. RENOVATIONS UIRE A IT PLAl�. - DATE: � 3� SIGNATURE: �,� PRINT NAME&TITLE: b I�i ST 1�(J5� fQ��, ; Rev.IO/12/16 p t/�/j,�` ' u� � i� v � � � �:�- V�AC , E''�.�� e,,� ,�.:,� t �� DEC 19 2016 aeaqroup WORKERS GOMPENSATION AND !- �''^ -�-`r.V�.. r,��-_� � EMPLOYERS LIABlUTY POLICY TYPE AR INFORMATiON PAGE WC 00 00 01 ( A) POLICY NUMBER: (6562UB-4705P92-8-16) RENEWAL OF (6562UB-47Q5P92-S-15) INSURER: ACE AMERICQN INSURANCE COMPANY 1. NCCI Cfl CODE: 12165 INSURED: PRODUCER: SONS OF ERIN CAPE GOD INC BRYDEN & SULLIVAN INS AG PO BOX 403 PO BOX 1497 SOUTH YARMOUTH MA 02664 SOUTH DEf�kVIS MA 02660 lnSured is A GORPORATION Other work places and identification numbers are shown in#he schedule(s) attached. 2. The poiicy period is from 08-02-i s to pg-02-�7 12:01 A.M.at tha insured's mai�ing address. 3, A. WORKERS COMPEN�ATION iNSURANCE: Part One of the pplicy applies to the Workers Compensation Law of the state(s) listed here: MA .� � = B. EAAPI.OYERS LIABILITY INSURANCE: Part Two af the policy appliss to work in each state Itsted in m� item 3.A. The ilmfts of our Ifabll(ty under Part Two are: �� Bodily injury by Acciderrt: $ 100000 Each Accident Q� BodNy Injury by Dfsease: $ 500000 pdtcy Llmit o� Bodily lnjury by Disease: $ 1 t�40o0 Each Empioyee � �= C. OTHER STATES INSURANCE: Part Three of the policy applles to ths states, ff any, listad here: � � COVERAGE REPLACED BY ENDORSENlE1dT WC 20 03 066 �� . � - � ...�� 0 „�� D. This policy inciudes these endorsements and schedules: — n� � SEE LISTING OF E�ORSEMENTS - EXTENSIQN OF INFO PAGE o� � � 4. The premlum far this policy wili be determfned by our Manuals of Rules, Classificatians, Rates and Ratt�g � Plans. All required IrrFormation is sub�ect to verification and change by audit ta be made anuUUua�LY. � DATE QF ISSUE: 07-19-16 WC ST ASSIGN; MA OFFICE: ORLANDO DA ACE 24M PRBDUCER; BRYDEN & SULLIVAN INS AC� 7�gK� 013882