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Home My WebLink AboutApplication and WC i ��ti..� ',. � 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 result in the return of your applicat�on pac et. ESTABLISHMENTNAME: ' '� ' ' • LOCATION ADDi2ESS: �• 'i�^^� TEL.#: '0 �--11 - �� MAILING ADDRESS:�t' sa �: E-MAIL ADDRES S: i r.F-�, � c.�\a,�AL .,�r��<<�n r �c��. OWNER NAME: ` CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: `T�`1.�c.,ti ..�v�, S TEL.#: 'S��f •"YlS�Q`�'S'C� MAII.ING ADDRESS: �aw�� -� 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. 1. �C��..'1 ��')-�-- �c�� 2. Pool operators must list a minunum of two employees curre�ntly ceriiSed in standard First Aid and Commutu�y 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. T7l�c..o:�.�.CC"� 2. �'l_J� �c...� ! 3. n�. M��, C _4. �,,.,.�,^ t�u � � �� _ ,� n ,'� FOOD PROTECTION MANAGERS-CERTIFICATIONS: -T �✓ 's 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. `;� +v �' ` 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. �� - L2. ��n�..._.�_.._.__ .' PERSON IN CHARGE: . Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. : i. 2• 7 � 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 , yj 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. � �: 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 anri-choking procedures below and � attach copies of employee certifications to this form. The I-Iealth Department will not use past years'records. Yoa must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE ERMIT# I,[CENSE REQUIRED FEE PERMIT# BBcB S55 �CABIN $55 . 17-00� 1 MOTEL E110 " (7..p 'INN SSS CAMP SSS �SWIMMINGPOOLE110ea ,#17_�� LODGE S55 =TRAILER PARK $105 �WHIRLPOOL SI l0ea: �/'��2� FOOD SERVICE: IJ�:ENSE REQUQtED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE RE�UIRED FEE PERMIT# 0.100SEA�'S 5125 CONTINENTAL E35 NON-PRO IT E30 >I00 SEATS $200 COMMON VIC. $60 —WfIOLESALE SSO —RESID.KITCHEN S80 ' RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE TtEQUIRED FEE PERMIT# <50sq R. S50 >25,000 sq.ft. 5285 VENDING-FOOD $25 =<25,000 sq.ft. 5150 �ROZEN DESSERT S40 �I'OBACCO SI l0 NAMECHANGE: SIS AMOUNT DUE = S �D��OO — — � "*•**pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***• �.A��N B�H'�-�IS'�65�0�2 ' �,,,crt�_go�t�t5-1�o5�P-o�- (o� Oo�SP-t5-165?-�Z Cwe� 6o►tsP-tS-�C�58-oZ f ADMINISTRATION ~ Under Chapter 152,Section 25C,Subsecdon 6,the Town of Yarmouth is now required to hold issusnce or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compens�tion 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 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 customariIy 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 thiriy(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 achedule 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 co(iform 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 Yarmouth Health Department by filing the requtred 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.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 Fmzen Dessert Permit until the above terms have been met. I� OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approvat 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. I'�'IS YOUR RESPONSIBILITY TO RETURN ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i r � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW � i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY BOARD OF HEALTH PRIOR ' TO CO N EMENT. RENOVATIONS MAY REQUIRE , DATE:�2' lO �b SIGN RE-'�..�--r'_"_ , PRINTNAME&TITLE:TIL��,�� —� 4^�''�ti-�' Rev.10/l2lI6 � k i A�!�a'� CERTIFICATE OF LIABILITY INSURANCE DA12/132016Y, 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 N,�E: Laura J Murphy HART INSURANCE AGENCY, INC. 243 MAIN STREET PHONE 508-759-7326 X207 ac No: PO BOX 700 ADDRESS: BUZZARDS BAY,MA 025320700 INSURER S AFFORDING COVERAGE NAIC p iNsuaeRa: NORGUARD INS CO 31470 INSURED Colonial Acres Resort Association INSURER B: 114 Standish Way West Yarmouth,MA 02673 INSURER C: 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. 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 CLAIMS. INSR 7ypE OF INSURANCE �DL SUBR pOLICY NUMBER MMIDD�YY MNUDDm P LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS•MADE �OCCUR PREM SES EaEoccur ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY�PR� � LOC PRODUCTS•COMP/OP AGG $ JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per pereon) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON OWNED PROPERN DAMAGE $ HIREDAUTOS q�pg P r cident $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MAOE AGGREGATE $ DED RETENTION $ A WORKERSCOMPENSATION COWC775466 OH/OlIZO1F) OS/O�/ZO17 PTATUTE ERH AND EMPLOYERS'LIABILITV ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $ SOO,OOO OFFICER/MEMBER EXCLUDED? � N�A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 5�0,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additlonal Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ��rr 1�� : � . ll � ��. �O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD