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Home My WebLink AboutApplication and WC� R�c�iv�� ' � TOWN OF YARMOUTH,�B�OARD OF HEALTH , � � APPLICATION FOR LICE�T j � ,- : - 1. : '� . a� SEP "I S 2O�� I �: « ' `'"' * Please complete form and attach all nec ' ' e b � Failure to do so will result in the re o a ica'ion . PT � ESTABLISHMENT NAME: P_4� - �Iac�crc��n �� ' Q- ��. TAX ID: ' LOCATION ADDRESS: A'?�{A �� , � ��i.r�(a�C•��c;p�l�,t�p� ��to�,�{ TEL.#: � v9k �� '' MAILING ADDRESS: '►-�c� �a�rr��a€�. un .W,�:y,� Va��=��v� , 1.�� i�LF��`� E-MAIL ADDRESS: OWNER NAME:_�'�'�.i� ci�{GtV 'VI�DV, �T v!��v Kou bc�y P v CORPORATION NAME (IF APPLICABLE):_.��S C.vr�� MANAGER'S NAME: 'Ztt�.� �c,yvt�C�Lv TEL.#:,�5pg T�9�- �$ MAILING ADDRESS: �(� �C`n��v,�al L`rr ,V,;cL�- ��C-hn��,�,� p,�(��-� , 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. 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. �';��c�r� ��.c b�.��v�- 2. `�Qm�� e��'Q�e�,r o. . PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. . 1. ��O�C�. ��U.'r�U'a... 2. �Q'�me.�,4- ��C�Q�Q�U C� 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. l. `��A��a v:,-.�b�,�v�e� �. 2._�C��5'��a ��o v 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. ��.c?r� V��.��,r��T�. 2. �c�� v�:;v , 3. 4. RESTAURANT SEATING: TOTAL# �� - . _, ______ _€3�+F� � _ --- -- -- ------ __- LODGING: � , 1 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 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $150 _FROZENDESSERT $40 TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ ( � S *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** f i ' � 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 11�ST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE 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 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 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)�lays,and � an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence ar 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 ar covered within seven(7)days of ' closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: AIl 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.varmouth.ma.us under Health Department, Downloadable�rms. FROZEN DESSER�'S: 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 pribr approval from the Board of Health. I OUTDOOR COOKING: ; Outdoor cooking,preparation,or display of any food product by a retail or food service establishment isprohibited. i 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 i TO COMMENCEMENT. RENOVATIONS MAY REQ A SITE PLAN. DA'�'E: ng� !S �a01� SIGNATURE: ' i G PRINT NAME& TITLE: TPJDc�.O�Ca V�9,�'�a`�oV Q. a�,h��" F � Rev. 10/12/16 � ' i i i � AC�� ATE(MM/D0lYYY1� �„� CERTIFICATE OF LIABILITY INSURANCE osi,si2o,� 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 have ADDITIONAL INSURED provisions or 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 ri hts to the certificate holder in lieu of such endorsement s). PRODUCER Benson Young 8�Downs.ins CONTACT Kathy Jones 565A Route 28 PHONE . (508)432-1256 F^X .(508)430-1532 P O Box 158 E'�'�A�� KathyJones@byandd.com Harwich Port MA 02646-0158 INSU ER AFFORDING COVERAGE NAIC# iN .NorFolk 8 Dedham Mutual 23965 INSURED BS�I C0� SURER 8: Yarmouth House of Piva INSURER C: 40 Bamboard Lane iNsuReR o: West Yarmouth MA OZB73- INSURER E: COVERAGES CERTIFICATE NUMBER: 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. NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH 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 E%P ICY N MBER LIMITS . COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CL41MS-MADE OCCUR DAMAGE TO RENTED $ MED EXP An one erson $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ POLICY�PR� �LOC PRODUCTS-COMP/OP AGG $ JECT TH R: $ AUTOMOBILE IJABILITY COMBINED SINGLE LIMIT $ A�A�T� BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS ONLY AUTOS � � HIRED NON-0WNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY $ UM6RELLA LIAB OCCUR EACH OCCURRENCE $ EXCE55 LIAB CLAIMS-MADE AGGREGATE $ DED RETE N g � /� WORKERSCOMPENSATION WE171540A 9��2�'�7 9/15/2018 X PER OTH- AND EMPLOYERS'UABILITY ANY PROPRIEiOR/PARTNER/IXECUTIVE Y�N E.L EACH ACCIDENT $ �OO,OOO OFFICER/MEMBER IXCLUDED? � N�A (MandatoryinNH) E.L.DISEASE-EAEMPLOYEE $ ��4,��0 If yes,describe under R TI N F P TI below ELDISEASE-POLICYLJMIT $ 500,000 DESCRIPTION OF OPERATION5/LOCA710NS/VEHICLES (ACORD 101,Additional Remarks Schadule,may 6e attaehed i!more space is required) Pizza Shop at 1311 Route 28,South Yarmouth,MA 02664. CERTIFICATE HOLDER CANCELLATION A1 059964 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELNERED IN Licensing Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 South Yarmouth MA 02664- AUTHORIZED REPRESENTATNE �;��. OO 1988-2015 ACORD CORPORATION. Ail rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD