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Home My WebLink AboutApplication and WC � � TOWN OF YARMOUTH BOARD OF HEALTH ��° � � APPLICATION FOR LICENS , - �� 2�� ``°� * Please complete form and attach all neces��s._ � ber 16 2016. Failure to do so will result in the ret" n k . ��; ESTABLISHMENT NAME: ": � � �'� TAX ID: LOCATION ADDRESS: ' �� p!�� TEL.#: MAILING ADDRESS: S r? ivlC� � E-MAIL ADDRESS: i ��' �i • C' C�� OWNER NAME: � � � CORPORATION NAME ( APP IC L ): ' � - (/ ��✓ / MANAGER'S NAME: � ��—�- TEL.#• MAILING ADDRESS: .� Sc>v v . c�l-2_ ,� .So 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 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 business. l. 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 m t provide new copies and maintain a file at your establishment. 1. L� 'J �_..-,-�CUi�t1V c.�� 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site duri, ours of operation. 1. � ,� �� ` 2. �� ALLERGE 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 must ' provide new copies and maintain a file at your establishment. 1. � � .r.1.�}�'C. � 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 m st provide 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# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 _TRAILERPAI2K $105 WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 T>100 SEATS $200 �� q COMMON VIC. $60 ��8 —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<2�,000 sq.ft. $$50 FROZEN DESSERT$$40 VENDING-FOOD $25 � �II _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ 3D0 ,p� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION ; Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hoid issuance or renewal l 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 4 � CERT. OF INSURANCE ATTACHED � � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: � YES NO ' I f MOTELS AND OTHER LODGING ESTABLISHMENTS I TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. I 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 dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Roam 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) i 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. r 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.�armouth.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: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: 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 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 COMME E NT. RENOVATIONS MAY REQU LAN. DATE: SIGNATURE: PR1NT NAME & TITLE: � G,l QI/�� Rev. 10/12/16 � .�-�-1 n+ESK�a-m .�aCo/�v CERTIFICATE 4F LIABILITY INSURANCE °"'�`�°°�""'' `----� �r�on TH1S CERTIFICATE IS ISSUED AS A NATfER OF iNFORMA'f�N 4NLY AND CONFERS NO RIGHT'S UPON THE CERTiFICA7E HOLDER.THIS CERTIFlCATE DOES NOT AFFlRMATIVELY OR NEGATIVELY AYEND, EXTEMD OR ALTER T1iE COA►ERAGE AFFORDED BY THE POLICtES BfIOW. THiS CERTlFlCATE OF INSURANCE DOES !�T CQNSTIME A CONTRACT BETYYEEN TttE tSSUNrG MtSURER(S),AUTHORIZEO REPRESENTA7IVE OR PROOUCER,AND THE CER7�lCATE HOIDER. IAAPORTANT: If the certificate holder is an ADDiT10NAL INSURED,the poucy(ies)must ha�re ADWTIONAL t�ISURfD provhio�or be endo�d If SUBROGATION iS WANED, subject to Ehe torn�s and conditions at the po�cy,oertain po�ci�msy requhs an andoraemerN. A stabsmer�on this certiflCaM does not conter ri W tl�e oeANicatie huider in lieu d wch eMOrsemer�s). raoot►c¢p �T Deisnd,Gibsan tnwrancs AswciaLes.lnc. wa� f�x 36 Washin�on Stteet Mo E : 1 237-1515 ,�p,: 61 237-1805 We1��sy t�uls,M�►o2ast .inEoC�?debnd b�n.cam asuaEWs)�o Coveut� wuc s r�su��:IYI�s RdaN Merchants WoNcers Gomp Grou r�un�a 1'he Skipper RestaurarN Beachvisw.Inc. 152 Sou�Sho►e Dr[ve South Yarmouth.MA 02664 MBUNBiF: RA ERT�{ TE PN111�ER: R N BE : THIS tS TO CERTIfY TMAT TME POLICtES OF NSURANCE L�TED BELdW HAVE BEEN ISSUED TO THE INBURED NAMED ABQVE FOR THE POUCY PERlOD INOiCATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CQN�iTION OF ANY CONTRACT DR OTHER DOCUMENT WITH RESPECT TO WHICH TFfIS CERTIFICATE MAY 9E ISSUED OR MAY PERTAlN. THE INSURANCE AFfORDED BY THE POLICiES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCIUSiQNS AND CONDITIONS OF SUCH POUCIES.UMNTS SHOWN MAY WiVE BEEN REO!}CED 8Y PND GLAlMS. "'� rnE oF r+s�uwce naucr au�n r E� �oucr ocr irurs ca�rert�u.aenEaLL u�urr � ClA1MSMADE OCCtkt DAMI4GE TO RENTEQ PAn a . � FER.SONAL dAQY IH.IURV S �NL A&GREGATE U#NT APPUES PER: C�NERRL AGG7i.EGATE S POLIC V j�� LOC PRODUCTS-CObPtOP AGG S OTM : AUTOMQBLLE LIABLLtTY COMB�D SINGLE UMT ��LL ..._. ANY AUTO 1 Y� Y�� r n OWNEO SGHEOUI.ED _. AUTOS ONLY AUTOS V RY r rl ...... A�S ONLY _.._.. AUTOSONLV .�ROPERTV UAIAAGE UI�REW UA8 OCCUR EACHOCCURRENCE S _.__.EXCESSLIA9 ClA1M5�MA0E AGGREGATE S DED RETENTION S a Al�E�PIO�RS��BB�nY X PER pTH• u ANYPROPRIETaRrPARTNEREXEGUTiYE TJM ptqppgp�g�g�17 Ot/01�2Dt7 011b11Z018 �� 1pp,ppp �QFrFIC�M�1.�ER E%CLUOED? N N!A � ' � M wa i f�rq OQ, P n yes.aesrnee�.,a� I F .P Y I . g�'�� D�CflIPl10N OF OPERATIONS f LOCATIONS!VBIIG�(IICORD 101.Addido�al RrwAs Sd�.n�yl W atrdrd tf nw�e apaw Fs reqinA► RTIFl TE �DER SMOULD ANY OF THE A80VE DESCR�ED POLICIES BE CANGELLED BEFORE E�� T!� EXPMiAT10N DATE THER6�F, NOTiCE MAIL 8E DELIVERED N ACCQRDANCE NIITH THE POUCY PROVL410NS. AUTiiQRQ�t�1�BRATNE ACORD 25(2016A3) �198&2015 ACOFtD CORPORATiON. All rights rosarved. ?he ACOliO neme and bgo aro ragis�red muks of ACORD