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Home My WebLink AboutApplication and WC� � ��c��v�D ' _ � °� TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSE/�'.,�RMIT:�20�'7 �' : T � , MAY J 3 �1117 ' �'°°� * Please complete form and attach all necess ��. d�c � h�''ts �' �' '�� ber 16 2016. Failure to do so will result in the ret f y 1 t i a EPT. � ESTABLISHMENT NAME: T� �'L� �'�I ;� F TAX ID: - '�'% LOCATION ADDRESS:_ ��'2 ��. �.S� TEL#• �'O �-7`7� -c� �/ ' MAILINGADDRESS: �c� /a�X ��l/ L4/ES'i ��,E�p�,�T�- oL � 73� E-MAIL ADDRESS: jd�, vK✓+�,��.,.,�. � G•,,,, � ( L�,,,,�, OWNER NAME: lt�� vY!�!1�2.rn�»4a I CORPORATION NAME (IF APPLICABLE): J�t.� � ; MANAGER'S NAME:__ ,Jc�� j/Jr�r�,_.Gq..�,� TEL#• q� -3'��-S y{��. I MAILINGADDRESS: nd [3o x � s�'i i,v�'�'�- v.� r•M�s� c.�z� 73 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. 1. ��c, C I ec.� ��r- �a�ve �� -e� c,.n�, 2. ��-c.-(,c� l' � r�� 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._ �!C�,d-t ( � rL.�� Q S �i�-- 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. 2, PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site durin hours of o eration. g P 1. 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' 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 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 .� Na�- op��s� anrG c� �oo�,g � LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE PERMIT# B&B $55 CABIN MOTEL I� $55 — $55 $110 � 7--Q _LODGE $gg C`�P 3 SWIMMING POOL$110 .17•OT r�8��i _TRAILER PARK $$OS _WHIRLPOOL $1 l0ea.� wor�b! FOOD SERYICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM]T# LICENSE REQUIRED FEE PERMIT# >100 SEATS $200 �CONTINENTAL $35 NON-PROFIT $30 VCOMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 k LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 � _45,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 � NAME CHANGE: $IS AMOUNT DUE _ � SS(��OO f i **''�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM � l�L—("j—�(.p�P f :r**** O C�)BoH�SP�{�-�i0-7 Co)4a�P-1�1��5 � C 6nwSP- �z-��tl : rw�odtsP-v?-4 U 3 r a i ADMINISTRATION f � � i 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 j Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR ' CERT. OF 1NSURANCE ATTACHED � OR � � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK G APPROPRIATELY IF PAID: YES 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 occuparrcy,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 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 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 � closmg. r f FOOD SERVICE P IN : � SEASONAL FOOD SERVICE O EN G � 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. � i I 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 obtamed at the Health Department,or from the Town's website at www.Xarmouth.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: -� - Oufidoor 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ; DATE: SIGNATURE: % PRINT NAME & TITLE: � , Rev. 10/12/16 Y F '�� GERTIFICATE OF LIABtLfTY INSURANCE °��"�'°°'"'�"' io 2$ �.� THS CERTIPICATE IS ISSUEO AS A MAl?ER OF INFORiULATiON ONLY AND CONEERS NO RtGHTS UPON THE CERTIFlCATE HQLDER THIS CER7IFICATE DOES NOT AFFIRMATfVELY OR NEGATIVEL.Y AMEND, EXTEND OR ALTER 7ME COVERAGE AFFORDED Rlf TFiE AOUqES BELOW. THIS CBRTIFICATE OF INSURANCE DOES NDT CONSTITUTE A CONTRACT BETWEEN THE i�SU1NG iNSURER{Sj,AUTHORIZEA REPRESENTATIVE OR PRflDIJCER,AND THE CERTIFlCATE HOI.DER. iMPORTANT: if the certificate hoider is an ADDITtONAL INSURED,the policy(ies)must be endorsed. If SUBROGATiON IS WAIHED,sulsject to the tarms and canditloru of the policy,certafn po1lcies rrray require an endorsement. A stat�ment on this certifiqte does not confer rl�ts to the certi$cate hotder in lieu of such endorsement(s}, r�owe�rt c NAME: _ Choiee Insurance Agency, Tnc. PH°Ne - '78.. 343-4853 '_ µ_ . ;Fax� + �y�a) 3a5-ioo� 376 Summer Street Fitchburg, Mp, plq�p ua�ss: chaice@choice-insarance.com INSURER(S}AFpORD{NG CpVERAGE _ � NAICIt iNsuR�a:Nor�uard Insurance Co. • lN5 UREO ITLSIIRER 8: ! 8andbar Management, Ina. _. ___._... _ _ _ , 1NSURERC.: _.. .__. __.�__..�____ . _ Cape Cod Inflatable Park 1NSUR6t D: . __.__�____._.____.__ _._._--- Po sox 481 .. ... . 1NSU,R,ER E: West Yarmouth, MA 02673 , .-.-____.._ ... - --..�_ _ . . . IIJ.SURER F: COVERAGES CERTIFtCA7E NUMBER: RE1/ISION NUAABER: THlS IS TO CERTIFY 7HAT THE pOLIC�S aF INSURANCE USTED BELOW FfAVE SEEN I5SUEDTO THE INSURED NAMED ABQVE FO(�THE POUGY PERIOD INDICATm. NOTWI7H5TANDlNG ANY REQUtREMENT,TERM OR CON01710N OP AN`f CONTRACT OR�THER DOCUMENT WRH RESPEGT 70 WHIGH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, FHE IN5URANCE AFFOImED BY ThE POLICIES DESCRI�D HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDI�'IqYS OF SUCH POIJCIES.LIMI1'S SHOWN MAY HAVE BEEN REDUCED BY PAID CIAtM& _ � ...�.__.�..________- _ ._ _ __„w...._. _ _-- --.. _ LTR TYPEORiNSURANCE AD�L'$(r�l�----- `" POLICYNUNBER -- _.r MM�� MSrodY�Y • _ LiMT5 ; GENERALLIA8ILITY �� ; ' EACH OCCUF7RENCE S �C(7MMERCIALGEN6RALLlABIt1TY ' �A�E��T�_ S " ' ' : _ ___. � �CIAIMS�AAO� ( i OOCUa ` � MED F�W(Atry ona pasm) S , i _ � � �PER50N4L&ADVIN,IURY 5�� . -—.-- � 5 GENERAL AC30REGATE 5 _.. , _- -_ __ _ : ---- - - _ -- -� . ._ .._ GEN'LAGGREGATEPIRMaTAPPUESPER � i j � PRODl1CfS_-03A�APAGG S ' POLICY� _ lOC S AU70M4811.E LIASIUYY t � , ` �aca"dart�IN LI_LIM $ ANY AUTO � � ' �OILY INJURY(Per person) S � ALLOWnED SCHECULED I � ' 8p011.Y INJURY(Per a�xitlenq�5 AUTOS AUTOS f ' a xitl � PROPERfYDAMAGE s ;__HIREDAUT�S �,,,,AUTOSWNEb � � j S , � � i j 1PereccideM� __ __ _._.. _... _ _ .____.._. .. ' � S UIYBREt1A LIAB O�CUR •---- I i EACH OCCURRENCE 5 EXCESSLIAB ,____ _ _ _ _... . _..__ ._ _._ .__ .r... . CLAIMS•MADE � �AGGREGA7E y $ . . _ . . . _ DED RETENTION S � $ A WORKE'Ft8 COMPENSATION , t g�y�C768346 10/7/16 10/1/17i �`�TATU- OTH- ANDEMPLOVERSUABILRY Y!N r- -T�� ._ _._ . ._. _ �_. ANY PROPRlEIOWFARTNERJEXECUTIVE OFFICEWNIEMBER EXCI[AED? � N!A; 3 j,E L EACH ACdOEPIf __ � �.�OOO f OOO (Mandatory in t3M) ; �E L DiSEASE-EA EMPLOY $ �.1 QOfl1 d��. I�f Yes,descrlbe ur,der ; . . . r�SCRIPTION dF OPERATIONS 6elnw ° °E l.DISEASE-POIICY LIMR S 1. OQ{) Q�0 : � � ; � � DESCRIPTIONOFOPERATIONSILOCA710N3lVEHICLES(AttaehACpRD107,AtlditionatReirerlcs$chedule,tfmorespaeeiareq�ired) CERTIFICATE HOLDER CANCELLATION SHOULO ANY OF'FHE A80VB DE5CRFBED POUGIE5 BE CANGELI.,ED BfFORE TI1E EXPIRA7tON DATE THEREOF, NOTICE WI�L. Bf DELIVERED IN Ik�ORDANCE W17H THE POLtCY PROVlSIONS. I�UTNORIZED REPRESENTAINE BTSa.Ti A1131T1 m 1988-2040 ACQRD CORPbRAT10N. All rights reserved. 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