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Home My WebLink AboutApplication and WCr a .� � TOWN OF YARMOUTH BOARD OF HEALTH REC E N E D p � APPLICATION FOR LICENSE/PERMIT-2017 MaR ? 7 �u�� *Please complete form and attach all necessary documents by December l6.2016. I Failure to do so will result in the return of your application packet. TH DEPT. � ESTABLI5HMENT NAME: "— TAX ID: �� LOCATION ADDRESS: TEL.# i MAILING ADDRESS: A DRIESSPPI�� E'G'tJ�'G'Y1�• 0. ;�...�`" ' ,:,� �,,� OWNER NAME: . � �� CORPORATION NAME(IF APPLICABLE): MANAGER'S NAME: � � TEL.#: MAILING ADDRESS: �- y _C/�rnn F -`�i � �T^� . POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool O�erator, as required by State law. Please list the designated Pool Operat r(s)and att ch a copy of the certification to this form. L 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 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�ess._ 1. 2. G� 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 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. �� AI�� u ,/ aY7 2. � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. i.�'/74.v'IP�'l�t1� /)�Al�� 2. 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'record . You m t provide new copies and maintain a file at your establishment. 1� � Y� 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. l. 2, 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L ENSE REQUIRED FEE PE # =B&B $55 CABIN $55 �MOTEL $110 �`�7"��{3 _L DGE $55 =TRAILER pp�$55 �_ SWIMMING POOL$11 WHI O ��'/��Z $ll Oea. #("7-0�✓g FOOD SERVICE: LIC NSE REQUIRED FEE P I # ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ��I7•��CONTINENTAL $35 NON-PROFIT $30 _>]00 SEATS $200 �/COMMON V[C. $60 �7.,��RES�ID.KITCHEN $80 �Oy}L-��']�3plty. RETAIL SERVICE: �.p LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#�l��p}y'SQ..�'1—�p�7 _<50 sq ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 =FROZEN DESSERT $40 _TOBACCO $110 �o�(�OFKQ�(']��J NAMECHANGE: $15 AMOUNTDUE _ $ � � ��$��SP�I7��Z2- �o��t��82y r , *x�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'T**** 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 Yarxnouth 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 ar 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 ninery(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shal]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 whiripools 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 opemng.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 inspechon three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparhnent, or from the Town's website at www.varmouth.ma.us under Health Department,Downtoadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to openin� and monthly thereafter, with sample results submitted to the Health Deparhnent. Failure to do so will result m the suspens�on or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE 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 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 COMPL�TED 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. � r DATE: � SIGNATURE: ` � . PR1NT NAME&TITLE: Rev.10/12/16 � _-----._ ...___....._ �. A�oRo� INSURANC� BlNDER °3i22i2o?;' THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TU THE CONDITIONS SHOWN ON '1'HE REVERSE SIDE OF THIS FORM. AGENCV COMPANV 81NDER M Gilmartin Insurance Wesco Insurance Company 1293 P03t RORd EFfECT1VE EXPIRqTION DATE TIME , DATE TIME X AM x 12 Q1 AM Warwick RI QZeBB 03j22/2017 12:�1 , PM 04/21/2017 NOON PHONE ��uC,No,EMt): �401)781-2100 �A� No�;I401)751-2201 TF{IS BIN�ER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY � CODE: SU8 COOE: PER E%PIRING POLICY N �� A6ENCY 00003729 . �]ESCRIP110N OF OPERA710NSNEHICLE5IAROPERTY(including Loutlon) . T MER I : INSURED '30 te 1 Al1 Seasons Hospita2ity, Inc. 1199 Route 28 South Yarmouth MA 02664 COVERAGES LIMITS � TYPE Of INSURANCE i COVERAGE/FORMS DEDUCTIBLE GOINS�L AMOVNT � PROPERTY CAUSES OFLOSS ' , BASIC BROAD SPEC GENERALLIABIUTY EACH OCCURRENCE S � COMMERCIAL GENERAL LIABILITY �AMAGE TO RENTED PREMISES a CLAIMS MAOt OCCUR MED EXP(My one person) $ PERSONAL&ADV WJURV $ GENERALAGGREGATE S RETRO DATE FOR CLAIMS MADE: PRODUCTS-COMP/OP AGG $ VEHICLE UABILITY COMBINED SINGLE LIMI7 S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS i BODILY lNJURY(Per accident) S 5CHEDULEU AUTOS PROPERTY DAMAGE S HIRED AUTOS �MEDiCAL PAYMENTS ;S NON-OWNEDAUTQS PERSQNALINJURYPROT $ ' UNINSURED MOTpR�ST $ S VEMICLE PHYSICAL DAMAGE DED - ALL VEHIf,LES SCNEDULED VEHICLES ACTUAI CASH VALUE COLUSION STATE�AMDUNT S OTHER THAN COL �' GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY: EACN ACCIDENT S AGGREGA7E S E%CE33 LIABIUTY EACN OCCURRENCE S UMBRELLAFORM AGGREGATE _ $ OTNER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE 'SELF-INSURED RETENTION S X WC STATUTORV UMITS WORKER'S COMPENSATION E L EACN ACCI�ENT f SOO,OOO AND 5��,00� EMPLOYER'S LIABILITY E� DISEASE-EA EMPLOYEE S � E.L.DISEASE-POLICY LIMI7 g 500,000 SPECIAL FEES S CONDITIONS! TAXES $ OTHER COVERAGES ESTIMATED TOTAL PREMIUM i NAME 8 ADDRESS MORTGAGEE AOOI710NALINSURED � - LOSS PAYEE LQAN# ,hL'THORI2E0 REPRESENTATIVE ci,� _, Joseph Gilmartin � � -V-• �`%'�' ACORD 75(2010104) Page i of 2 OO 1993-2070 ACORD CORPORATION. All rights reserved. INS075�20�ooa�oz 7he ACORD name and logo are registered marks of ACORD