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Home My WebLink AboutApplication and WC �� e �^� 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 applicauon pac cet. �` ESTABLISHMENT NAME: ,r `' .�,v� � LOCATIONADDRESS:'1� r��. <-c S. ��Zr.c-v. TEL.#:•'rj�X_'3`i�'• '111� MAILING ADDRESS: E-MAII,ADDRESS: �n b (c�r I5'�tr °7 C�d� n�r►�,�,.a�rn S .t°c..�...� OWNER NAME: � CORPORATION NAME(IF APPLICABLE): � MANAGER'SNAME: � ��,A��,�� L.#:-��-�t�- � �� MAILINGADDRESS:___`�o� „ , �-e..,�t-.— ,� - '?' p �,�u;::i POOL CERTIFICATIONS: � c-m7 ��'i The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated � ��r; Pool Operator(s)and attach a eopy of the certification to this form. �� s 1. � C�F.�5� .c�-c �(!'b�S 2. �_� '� � � Pool operators must list a minunum of two employees currently certified in standazd First Aid and Community �« Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all dmes. Please list the ': employees below and attach copies of their certifications to this form.The Health Department will not use past ..v____.�.�__...__.._.� years'records. You must provide new copies and maintain a file at your place of business. 1 "�ltc t��. �J 2. C� �r-� �av-. 4 ,:�'� 3.��. C ac... 4. C �L ,..�.� ^---� �,,� 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 and maintain a file at your establishment. �..<:';r�. L 2. . � _�. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments aze 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 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 a11 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L ENSE REQUIRED FEE P RMIT# Z B�B S55 CABIN S55 �MOT'EL 5110 �NA1 SSS —CAMP $55 �SW[MMING POOL SIlOea � S( _LODGE S55 TRAILERPARK SI05 �WHIRLPOOL S110ea. �� FOOD SERVICE: LICENSE REQ UIItED FEE PERMIT# LICENSE REQUIREA FEE PERMIT# LICENSE RE UIRED FEE PERMIT# 0-100 SEATS 5125 _CONTINENTAI, S35 NON-PRO�IT S30 >l00 SEATS a200 _COMMON VIC. S60 —WIIOLESALE $80 —RESID.KtTCHEN a80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. S50 >25,000 sy.R. $285 VENDING-FOOD S25 _<25,000 sq.ft. �150 =FROZEN DESSERT S40 =TOBACCO SI l0 NAMECHANGE: SIS AMOUNT DUE _ $ �� C� **�*tPLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•*•"* �0,�.��c _�f�OQ—6 2 T' U l �� F��l�SP�IS-Ibtb --�-� C�� o�-sP�t�—[a�l—�z r 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 permit to operate a business if a person or company does not ave a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S CO ENSATION INSURANCE AFFIDAVTT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth ta7ces 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 limita6ons 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 tivriy(30)8ays,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 DeparUnent to schedule the inspecNon three(3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: T'he 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 reqwred Temporary Food Service Application form 72 hours prior to the catered event. T'hese 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+lierea#tcr,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocarion of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�`S: t ave rior a roval from the Board of Health. Outside cafes i.e. outdoor seatin with waiter/waitress service mus h � � S )� P PP i I' 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 RENOVATTONS 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 MAY REQUIRE A SITE PLAN. ' ' DATE: SIGNATURE: ' PRINT NAME&TITLE: x�.iaivie 9 + A�� CERTIFICATE OF LIABILITY INSURANCE DA�ZI'I3IZO1FiYY) 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(les)must have ADDITIONAL INSURED provisions or 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 ri hts to the certificate holder in Ileu of such endorsement s). PRODUCER N�E, Laura J Murphy HART INSURANCE AGENCY, INC. PHONE , (508)759-7326 aC No:(508)759-7366 243 MAIN STREET E-MAIL PO BOX 700 nooeess: Imurphy@hartinsuranceagency.com BUZZARDS BAY,MA 025320700 INSURER S AFFORDING COVERAGE NAIC# iNsuaeaa: Associated Em lo ers INSURED Pier 7 Condominium Trust INSURER B: 711 Route 28 South Yarmouth,MA 02664 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 SEEN 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 TYPE OF INSURANCE ADDL SUBR pOLICY NUMBER MM/DD/YYYY MM/OCDY YYY LIMRS L R COMMERCIAL GENERAL LIABIIITY EACH OCCURiiENCE $ CLAIMS-MADE � OCCUR PREMG ESO F?ENTED n $ MED EXP(Any one erson) $ 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 ccident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEOUIED BOOILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY�AMAGE $ AUTOS ONLY AUTOS ONLV Per acciden� $ UMBREILALIAB OCCUR . �EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ A WORKERSCOMPENSATION 5011467012016 08/01/2016 08/Ol/2017 PTATUTE ERH AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $ SOO,OOO OFFICER/MEMBER EXCIUDED? � N�A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,000 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) Operations as performed by Terms&Conditions in the policy CERTIFICATE HOLDER CANCELLATION Town of Yarmouth 1146 Main Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE South Yarmouth,Ma.02664 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORI2ED REPRESENTATIVE ��'r�� _ �r �_� OO 198&2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD