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Home My WebLink AboutApplication and WC J��'-�G�S-� �� 'o� � � ��..��>,� i � � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/PE T-� � , � DEC 21 2016 . �.. �: � ��-c�� * Please complete form and attach all nece�Ssa�r�Y�ments by De`e ber 16 2016. Failure to do so will result in the re�urn o�yvur�app�i�aticsn p ._ _�_�!,.:....,�o_, �._:. ESTABLISHMENT NAME: TAX ID: � LOCATION ADDRESS: � U �� TEL.#: �J� � � �/ MAILING ADDRESS: Q cI E-MAIL ADDRESS: � (,{,til C�S�XS �Ft � . , OWNER NAME: �l'1.11l�� U�p D lI �t�P�' CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: s2 �, Gc. TEL.#: b�U �S � � MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisar must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator�s) and attach a copy of the certification to this form. -- __1 _ ___— _ _---- — ___---�. __ 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 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. 2. 3. 4. 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. 1. �� L l�t.�2 rS 2. �oo o� 5v�� . ��w nn�s� �;�.�mvv� l��vnct,i s�hov 1 ��5�-ic f ERS07�,T I1�1 CNARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �� 2. hnt5 (��rrnc�� j��nc� � �� hov I 1�c5�ia f �vd S�w�e�s A LERGEN ERTIFICAT ONS: 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' reeords. 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 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. rit, � 2. 3• C,� 4. RES'I'ALTRANT SEATING: TOTAL# I�J L� ; _ _ OFFICE USE ONLY ---- — LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,. LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $I10 —I� $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 ��`�� COMMON VIC. $60 �� —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR�D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ o/�,U **"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �o�F-��-O�6�-03 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 INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LOB�IioTG 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 dweJling 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 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 required 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 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 Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outsic�e cafes(i.e.,o�oor sea��uith waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN 'I'HE 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 REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ��j�� SIGNATURE: G� PRINT NAME& TITLE: Rev. 10/12/16 ��t�� .��, ROMACAT-02 KGOUVEIA ACORO� DA�c•+Miuommr� �,� CERTIFICATE OF LIABILITY INSURANCE �2nno�s 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(Sj,AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(fes)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 certiflcate does not confer rtghts to the certificate holder in lieu of such endorsement(s). PRODUCER LIC@11S@#'I7SOHG2 ��E� LuCia Mendes HUB Intemational New England PMONE 508)235-2210 a No: 222 Milliken Boulevard ac No E�: Fall River,MA o2722-9946 �REss:Lucia.Mendes hubinternational.com INSURER(3)AFFORDING COVERAGE NAIC� INSURER A:�O�ated Industries of AAassachusetta MuWal Inauronce Compan 33758 INSURED INSURER 8• Roman Catholic Bishop of Fall River, INSURER C: Corp.Sole P.O.BOX Y57� INSURER D: Fall River,MA 02722 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE PbCfCIES �F INSDRANCE LISTED BEtOW 1iAVE BEEPt ISSUED TJ�HE INSUREDN!lME�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 pp�NSURANCE POLICY EFF POLICY EXP LIMITS LTR N YWD POLICY NUMBER MWD MMIDD COMMERCULL GENERAL LIABIL.ITY EACH OCCURRENCE $ CLAIMS�IADE �OCCUR PREMISES Ea occurrence S MED EXP(My one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE IIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY��EC7 �LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A�p��B�m, COMBINED SINGLE LIMIT $ Ea aceident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per acadent) $ AUTOS NO OWNED PROPERN DAMAGE $ HIRED AUTOS AUTOS Per accident $ �� OCCUR EACH OCCURRENCE $ �� CWMS-MADE AGGREGATE $ DED RETENTION$ 3 WORKERS COMPENSATION �( AND EMPLOYERS'LY161LfiY STATUTE ERH A ANY PROPR�TORIPARTNEWEXECUTIVE Y� N�A MZ80080066832016A 07/01/2016 O7/O'I/YO'I7 E.L.EACH ACCIDENT $ ��OOO�OO OFFICER/MEMBER EXCLUDED4 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE 3 �,OOO,OO Ifyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ �,OOO,OO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,Addklonal Remarks Sehedule,may be attached H more apace k requlmd) RE:St.Pius X School,327 Wood Road,So.Yarmouth,MA 02664 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Heelth DiVi8io11 ACCORDANCE WITH THE POLICY PROVISIONS. 1146,Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTAi1VE ��1�� 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(201M07) The ACORD name and logo are registered marks of ACORD Florio, Mary Alice From: Florio, Mary Alice Sent: Wednesday, December 21, 2016 1:43 PM To: 'mgogan@spxschool.org' Subject: 2017 License Application Fee Dear Ms. Gogan, First of all, I want to say I am so sorry to hear about the passing of your mother,and send heartfelt condolences to you and your family. Secondly, I would like to thank you for submitting the application for the St. Pius X School food service and common victualler licenses, however,there was no payment enclosed with the application.Would you please send the$260.00 payment(payable to the Town of Yarmouth)to the attention of the Health Department at your earliest convenience? It would be greatly appreciated. Again, I send my condolences, and hope that you and your family will be able to find peace during this Christmas season. Sincerely, MaryAlice Florio, Principal Office Asst. Yarmouth Health Department 1146 Route 28 South Yarmouth, MA 02664 508-398-2231, ext. 1241 i � �-� . . . �� oEc z I � 2o�s ► � ��-�s �„ �,�-. � � �:�.R,_ ,_� , -,�.. ; ---=�=-�.�.�__�� December 19, 2016 Town of Yarmouth Health Division 1146, Route 28 South Yarmouth, MA 02664 Dear Sir or Madam, I apologize for this late submission. My mother passed away suddenly in late November, and I have been trying to catch everything up. Please let me know if there is anything else I need to provide you with. Sincerely, Maura Gogan Business Manager St. Pius X School 508-398-6112 - 3z1 Wo-oal. TZo-ad• • So�u�.Yu,rww-u��•�,, Iv� 02�0�04 • 508-398-�0112 • www:s�-yU�c�,on{.org