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Home My WebLink AboutApplication and WC i �� TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 " *Please complete form and attach all necessary documents by December I6 2016. Failure to do so will result in the return of your applicat�on pac cet. ESTABLISI�MENTNAME: � T •O - � LOCATION ADDRESS: �Q 3 Ot,rl�-c� Z� �.11.�'u,a-tr�ai� M A TEL.#: SO��?�I I-:�(o(�,,(�, MAILINGADDRESS tQ3 2�c31r 2p �„rc�+ y mo iri I�L1� �2.G�� E-MAIL ADDRESS:C�I C d I�c''_c.v Z'I S E� C.O V�.!A varcm�u�f h. C�w� OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: i t� aI TEL.#: c7 - ' I�" �. �032 MaII.INGaDDxESS: " q`�'��Q lc�,il,� 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 eopy of the certification to this form. � �. �r a�l �'�I�.�a.r-�s z. Chw-��s��'1 j 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 rrt �-�; � employees below and attach copies of their certificafions to this form.The Health Deparhnent will not use past � �—^ �,� years'records. You must provide new copies and maintain a file at yonr place of business. —rj �, � Y i. DI t ca��,s-�� a-�-fG r�t d 2. o � � 3�— 4. � � � -� � � ' FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one fixll-time employee who is certified as a Food Protection Manager,as defined in the State Sanitary Code for Food Service Establishxnents, 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. •, l. 2. , PERSON IN CHARGE: � a Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. �_, � ; 1. 2. ��„-� � ' ALLERGEN CERTIFICATIONS: L All food service establishments aze required to have at least one full-fime 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. 2. HETMLICH CERTIFICATIONS: E n� r� 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-chokuig procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years'records. t� � p p You must provide new copies and maintain a file at your place of business. * � �r � ` ` �h ,p .� '�'O ' 1. 2. � � l � .�-. 3. 4. N� «� ti1 Vl .1. RESTAURANT SEATING: TOTAL# ,, .'j'� N � �' � n OFFICE USE ONLY � � p +o � LODGWG: � f � ^' r L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMI �V �„ B&B $55 CABIN $55 1 MOT'EL $110 ('7—��) INN $55 —CAMP $55 �SWIMMINGPOOL$110ea. O�S�O!(e _LODGE $55 _TRAILERPARK $lOS �WHIRLPOOL $110ea.�-+f FOOD SERVICE: LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT�t 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN S80 RETAIL SERVICE: 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 $1 l0 NAME CHANGE: $IS AMOUNT DUE _ � **•**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 campany does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLE"�'ED ANA SIGNED,OR CERT.OF INSURA.NCE ATTACHED� OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � N� � 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 hote2 use. Transient occupants must have and be able to demonstrate that they maintain a principat 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 collecrion 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 aze NOT allowed to sit in the pool azea until tfie pool has been inspected and opened. POOL WAT'ER 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. 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 Yazmouth Health Department by filing the required Temporary Faod Service Application form 72 hours prior to the catered event. T'hese forms can be obtained at the Health Departtnent,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 Deparkment. Failure to do so will result in the suspension or revocarion of your Frozen , Dessert Permit until the above terms have been met. OVI'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 dispiay of any food product by a retail or food service establishment is prohibited. i � NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET[JRN � THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i ' ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR i TO COMMENCEMENT. RENOVATIONS Y REQU A SITE PL . ' � DATE: jO J Z� �I Lm SIGNATU • : PRINT NAME&TITLE: G Cd�/V�'c.� Rev.10/12l16 ��J�'j.{,y��,�,, /I ►G-r1�+fjA,� V� Ac�� CERTIFICATE OF LIABILITY INSURANCE �TE(MM/pDlYWY) �'' a/si/2oss THIS CERFIFICATE IS ISSUED AS A MATTEi� OF UVFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER71FICATE HOi.DER. TliiS CERTIFICATE DOES NOT AFFIRMAFNELY OR NEGATlVELY AMEND, EXTEND OF! ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TH1S CERTIFICATE OF INSURANCE DOES NOT CQNSTiTUTE A CONTRACT BETWEEN THE ISSUtNG INSURER{S), AUTHORIZED 2EPRESENTATfVE Oit PRODUCER,AND FHE CERTiFICATE HOLOER. IN�ORTANT: IP the certificate hofder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditfons of the poticy,certairt pollcies m8y require an endorsement. A stater»enE on this certiffcate does not confer rights to the certifrcate holder in Ileu of such endorsement(s). PROpUCER CON ACT B1ane L•a�3xn NAM : ThE Armstrong Company Inauranoe COIIBLiltailt8 Pn��°N a.Ext�. (910)530-0099 ��No,,{310)530-0098 _ _ 2780 Skypark br, Ste 440 EppR�$.daazmain@armstroaginsao.com ,INSURER_(S�AFFDRDING CDVERAGE NAIC t� Torranae _i__ CA 90505 1NSURERA;ARlBra.CSA 3tates insuranae Co � �19704 INSURED INSURER B:Peerless Insurance COSCi_p�� _ 2q19$ �——.— Cove at Yarmouth Resort HotQl owners Associa�ion Ync �NgurteRc:Travelers Praper� Casualty Co of 25674 183 Main Straet rwsu�tErto:Westahester Su Ius Linea �10I72 rP —.—.—.--.----._.—..—.._ 1NSURER E: Weat Yarmauth MA 02673-4653 ^ --------�.— — i INSIJ RER F: COVERAGES CERTlFICATE NUMBER 16j17 Liabllity & Prop REVISION�IUMBEFt; THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN fSSUED TO THE INSURED NAMED ABOVE FQR THE POIICY PERIOD INpICATED, NOTWITHSTANpING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRHC7 OR OTHER DOCUMENT IMTH i2ESPECT TO WHICH THIS CERTfFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRI6ED HEREIN 1S SUBJECT TQ ALL THE 7ERMS, EXCLUSiONS AND CONDlTIONS OF SUCH PI�IICIES.lIMfTS SHOWN MAY HAVE BEEN REDUCED BY PAID ClA1MS. �L7R TYPE OF IN3URANCE � PD CY NUMBER PO�IpY EFF PO�L�fCY� uMITS � I X I COMMERCIAL GENERAL LIA81l,ITY � � L�Li � I � I I EACH OCCURRENCE �$ 1�000,OUO '' A � j CLAIMS-MADE ��OCCUR � PR�MISES�LFa occ��wre ce S 100,000 �..—��—.. ? � I 01CH38480400 4/1/2016 9/1/2017 �MEo EXP(Any one erson $ S0,ODO �--�—•--------- I P ) _� ._.�_._._._ PERSONAL&AOVlNJURY ,$ � 1,000,000 �GEML AGGREGATE LIMIT APPLIES PER: � QENERAL AGOREOq7E $ 2 r 000,000 I �'—---- I�POLICY L J JECT CJ LOC I PRODUC7'S-COMP/OP AGG"$ 2�000,Q 00 OTHER: { Emplayee Benefds $ �i,000,000 �qU70MOBILE LIABlUTY �C MBINED I L L IT t— Ea sccideMY._ $ 1�000,00� �X�ANY AUTO � I I i 8001LY INJURY(Per person) '$ I~I�qlL OUVNEU f'�SCHEDULED i +gp,6756492 4/1/2016 ` 4/1/2017 BDDILY INJURY(Peraccident) $ AUTOS L A U TOS I J�� IHIREa AUTOS �_'q�OS�E� I I �P OPERTV OAMAGE '$� "� --1 I � _L r acc4dent)—'--`—�---.—--. I $ I XJ UMBRELLA LlAB �X pCCUR i � � I EACHOCCUF2RENCE — $ 25 000 000 �.�____�._�_J.-.-_.� .� C ��Ss��AB � C�.AIMS-MADE � AGGREOq7E ��$ 25,000�000 ' DEO RETEN716N$ � '�� 4/1/2016 4/1/2017 I$� WORKERS COMPENSATION � + �`T �� ; AND EMPLOYERS'LlABlLITY Y!N I I X 'STA TE Ei2��----'_---. ANY PROPRfETOR/PAR7NER/EXECUTfVE r E,L.EACH ACCIDEN7 $ 1 000 000 A OFFICER/MEM6ER EXCLUpED? I� N/A �_^�i_,__ � (MandBto ry i�NH� (O1WC37589950 4/1/2 0 1 6 I 4/1/2 0 1 7 ;�,L.p I S E q S E-E A E M P L O Y E $ 1�000�000 Ifyes,desctibe under —� ---- DESCRIPTION OF OPERA770NS b low E,L OISEASE-POLICY LIMIT� 1 000 000 I b I Property - Special Form I D374o6107 4/1/2016 a/i/2017 Primary LimR:g10,000,00o Ded. $5,000 l IInGluding NdYned Storm IlnGudedin Prunaty Limil Ded. S� �ESCRIPTION OF OPERATIONS!LOCATiDNS!VEHICLES(ACORD 701,Adtlltiontl Remarka Schetlule,may be attached if more space is requ'red} � The Certificate Holder is hereby named Adc3itior�al Ynsvred with reapects to the property and g�neral Iiability lacated at: 183 1�ain Street, Route 28, West Yarmouth, MA 02673-4653 but only as their interest may appear. �� *"klO CI3�( Npti1CB af Cancellation for non-payment of premi.um. GERTfFICA7'E HO�DER CANCELLA7iOIV SHOULD ANY OF THE ABOVE DESCRfBED POLICiES BE CANCELLED BEFORE Town o� Yarmou'�h 7NE EXP(RATION DAT'E THEREOF, NOTICE WiL4 BE DELNERED fN Route 28 ACCORDANCE WITH THE POLiCY PRpVIStONS. South Yarmouth, MA Q2664 AUTHORIZED REPRESENTATIVE �196$-2014 ACORD CO N. I!rights r�servad. ACORD 25(2014/01) The ACOFtD name and logo are registered marks of ACORD � INS025{zo�4o1>