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Home My WebLink AboutApplication and WC �: � 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 applicat�on pac et. ESTABLISHMENT NAME: (Y� 2 — LOCATION ADDRESS: `T 'T TEL.#: SO$ $� I Q� � MAILING ADDRESS: S O ��, �t5 -�(� O` E-MAIL ADDRESS: i�1 1f'(1 Y� OWNER NAME: � N " � 'i CORPORATION NAME(IF APPLICABLE): Y C 1 � _� �, I MANAGER'S NAME: N S 1�J}� TEL.#: O eF� �;> ?'' +` i MAILING ADDRESS: . � _ Z ,, ; _� O 9 � _ w ,3 POOL CERTIFICATIONS: _� The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated , " p ' Pooi O eratar s and attach a co of the certificarion to this form. --' ` ° P � ) PY �--i .� 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 L employees below and attach copies of their certificatians to this fonn.T6e Heatth Department will not use past � '�� years'records. You mast�rovide new cop[es aad neaintain a fi1R at yoe�r place of bt+siness. ��.� l. 2. _�, 3. , `�' i �s<� 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. �p;t . Please attach copies of certificarion to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. �. ��i� �{ �}S �-i� N �-��V 2. ��2 G i �f�-Z�}ko1/ : PERSONIN CHARGE: Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. �. �fi i�- N�-S �T�-N�+�Dv 2. ��ORG� L��RaV 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 mnst provide new copies and maintain a file at your establishment. �. �- t �-�v�-s R�� n�A-Sov 2. G�O�GI L� Z�R� D�V HEIMLICH CERTIFICATIONS: All food service estabiishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at atl times. Please list your e.mployees trained in anti-choking procedures below and attach copies of employee certifications to�.his form. The Health Departm�nt wiil not use past years'records. You must provide new copies and maintain a file at your plaze of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUiRED FEE PERMIT# LICENSE REQUIRED FEF. P£RMIT# LICENSE REQUIRED FEE PERMIT# BBcB $55 CABIN $55 MOTEL SI10 INN S55 CAMP $55 SWIMMING POOL$I l0ea. �,ODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE ��R-7MIT/�� LICENSE R6QUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-l00 SEA7'S 5125 ��"r`_"2. CONfINENTAI, S35 NON-PROFIT S30 >100 SEATS 5200 �COMMON VIC. S60 ��9 ��D K TCHEN $80 RETAIL SERVICE: LlCENSE REQUIRED FEE PERMIT# LICENSE REQUIREll FF,E PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25,000 sq.ft. 5285 VENDING-FOOD $25 —<25,OOOsq.ft. $ISO _FROZENDESSERT $40 _TOBACCO $I10 NAME CHANGE: S15 AMOUNT DUE _ � 18�.C�t� •*••*PLEASE TUkN OVER AND COMPLETE OTHER SIDE OF FORM*•••• �o I��-tS- (Z6 S-02 � 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 INSURAIYCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR � CERT.OF INSURANCE 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 V 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 demonsuate that they maintain a principal place of residence elsewhere.Transient occupanc„r•shall generally refer tc�continuous o�cu�an.cy of not more than thirly(30}days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest i�nit as a residence or dwelling unit shall not be eonsidered transient. (�ccupancy that is subject to tlie coliection 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 State certified lab, and submitted to the Health Department three(3)days prior to opening, and quarterly thereafter. POOL CLO5ING: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 Yannouth must notily the Yannouth Health Department by filing the requued Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Departrnent,or from the Town's website at www.vannouth.ma.us under Health Departrnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a StaYe certified lab prior to operung 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd 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 RENOVAT'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW F.QUIPMENT,ETC.),MUST BE REPORTED TO AND APPR VED BY HE BOARD OF HEALTH PRIOR TO COMMEN EMENT. RENOVATIONS MAY REQUI ITE P N DATE: I� �D ZO iC7 SIGNATURE: PRINT NAME&TITLE: /Q � �^ )`-'/e�s/ �N^ Rev.10/11/16 ^ �rncno `s 1��2� , Y� ��u�. ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DDIYYYY) �� 12/19/2016 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 CONTACT COIDID@TC131 Lines NAME: Risman Insurance Agency, Inc. PH�E . (781)396-2116 aC No:(781)395-2300 689 Fellsway E-MAi� ADDRE55: INSURER(S)AFFORDING COVERAGE NAIC# Medford MA 02155 INSURERANOY'fOlk & Dedham Mutual Ins Co 23965 INSURED INSURER B: KC PIZZA INCORPORATED DBA DOMINOS INSURERC: 65 THORNBERRY CIRCLE INSURER D: INSURER E: � MASHPEE MA 02649 � INSURER F: COVE�2i4GES CERTIFICATE NUMBER:CL16121914042 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 ADDL SUBR � POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYV MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP(My one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑jRC7 �LOC � PRODUCTS-COMP70P AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Peraccident) $ . AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y�N STATUTE ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ SOO OOO A OFFICER/MEMBEREXCLUDED? �N�A (Mandatory in NH) WE115956A 9/12/2016 9/12/2017 E.L.DISEASE-EA EMPLOYE $ 500 000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,Addkional Remarks Schedule,may be attached if more space is required) Insurance verification - Please refer to actual policy for all other terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PROOF OF COVERAGE ONLY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Nicole Bobocea/NICOLE -`�� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r�mann