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Home My WebLink AboutApplication and WC, �^' �� TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE/PERMIT-2018 ` *Please complete form and attach all necessary documents by December I5.2017. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: t��n AK rrf U n C A -- � LOCATION ADDRESS: .7 TEL.#: 'a�S — 77/' �� MAILINGADDRESS: Gvt f t�a 19 U E-MAIL ADDRESS: t r� w►r►H^�� C�G�C�t S f ' �°I{t OWNER NAME: t .4 `3 h n�n CORPORATION NAME(IF�A PPLICABLE): MANAGER'S NAME: (�Crcq./(t q nM�n TEL.#: y-8'7a� MAILING ADDRESS: o� Lu'�<K '�'t • �(J. Kt�►d ' G� L 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 m � years'records. You must provide new copies and maintain a file at your place of business. D � � 1. 2, _ � Ri 3. 4• � ev � � o � 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. �� V � 1 2. � L� PERSON IN CHARGE: - ��;� l�,�� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � � „ 1. 2, ��t �•� � � s � Z ALLERGEN CERTIFICATIONS: �-��+'�'� ' O All food service establishments are re uired to have at least one full-time em lo ee who has Aller en certification, "`�� '�' � as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach �"V 1� 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: U � 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 fle at your place of business. 1. 2. 3. 4. r RESTAURANT SEATING: TOTAL# `r OF�'ICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED 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 $110ea. FOOD SERVICE: �� I�� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR$D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 =>100 SEATS $200 � �COMMON VIC. $60 �y _WHOLESALE $80 —o I RETAIL SERVICE: —RESID.KITCHEN $80 �,.1 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �fL��+"'�`�'� <25;00 s ft. $$50 —�z5,000 sq ft. $285 _VENDING-FOOD $25 — 9� _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ Z�CO;Q� *****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 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 f{/j(I VP F�K� 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)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 far 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.varmouth.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 3 L TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY T BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE iRE S . DATE: �d�as � � SIGNATURE: PRINT NAME&TITLE: G t�A rlI �JH IM S �n� ��C. x��.wnzit� �Or,t. 2�, 2�117 11 :39AM � Nn. 7243 �P. l�row�� '�cU'�u CERTIFICATE QF LIABILITY INSURANCE iolz��2oi7 TH13 CERTIF(CATE IS ISSUED RS !►MAnER OF INFOflMAT10H ONLY /WD CONFERS NO RIGHTS UpON THE CEHTIFIGATE MOLDER. THIS CERTIFICATE DOES NO7 AfFIRMATIVELY OR NEGATIVEIY AfAENp, EXtEND OR ALTER TFIE COVERAt1E AFFORDED BY 7HE POUCIES BELOw. THIS CER"fIFICATE OF IN9URANCE DOES t�07 CON3TITUTE A CON7RAC7 bE'�WEEN THE ISSUING 1NSURER(S), AUTHORIZED REPRE5ENTATIVE OR PRODUCER, AND 71iE CERTIFICATE HOLDER. IMPORTAN7; If Ibe canlflcata holder ie an ADDlT10NAt IN9URED,th0 pollcy(I�s)mu9t be endors9tl. H SUBROQATION IS WAIVED.9ub�eei to the terms end condlUons oi the po�lcy,cerlain poIIG65 may reAu�re a�endoreement. A s[ateme�+t on Ihla eeANlcate doe9 not contsr rlphts io`the ceniflcate holdBr In tleil of such endorgement(a). PR.ODWCER ... NAM6- � . . MCSHEA ZNSUIi�iNCL AGENCY INC HO:VE (508�420--9011 ao.(50'B)920-9010 1550 Falmduth Rd 5te �2 A No£fi: Centerville, MA 02632 aooaEss:insure@mesheainsurance.com 118UREp(B) AFFOHUwc3 GOVERAGE Itl4C� �NS�qEp^:Tt1e' Hartford Insurance Company � INSURED Captain Parkers Pub, Inc. �suAeR a.�National Grange Mutual Ins Msnr�ing, Ger11d IPISUREFi C;TrIA Hartford Insurance Canpany 666 Ma.in Street ir�suweao: W. Yarsnouth, M� 02673 INSUqER E: 5ae-��.-a2s6 INSURERF: COVERAGES C6RTIFICAT6 NUMBER: REVISION NU�BER: THIS IS TO CERTIFY THAT THE POL�CIES OF INSURqNCE USTED BELOW HAVE BEEN ISSUED 7'O THE INSURED NAMED ABOvE FOR THE POUCY PERIOD INDICATED. NOTWI7H$7qNDWG AINY REQUIREMENT,TEHM Oii COND�T�ON OF ANY CdNTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIGH THIS CERTIFICATE AMY BE ISSUED OR MAY PEqTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE5GRIBED HEREIN 15 SUBJEC7 TO ALL TWE TERA0.S, i ERCtUSIONS AND CONDITIQNS dF SUCH POLICIES.UMITS SHOWN N(AY HAVE BEEN REDUCED BY PAID CIAIMS- � ��q P/PE OF�NSURANCE PQLICY NUM6EH MNUDDlYYVY M LIMITS GEN6RAl LIQBIL�T' Eacn OCCURRENCE $ ZOOOOOO 3C COMRAERCIAL 6ENEFiAL LIRBILtTY PflEM13ES Ea occurre++ce S 1dO�OOOO CtAiMfi•MADE Q OCCUR MED EXP(AnY one p�ireon� S Jr��0 A OSSBANXSQ37 a/5/2oi� a/5l2oi8 pERSONALBADVIkJURV s 2000000 GENERAI A0t3RE(3ATE $ 4 O O O O O O GEN'LAGGREGA7EUMITAPPLIESPER: PRODUCTS-COMP/OPAGG S '4000000 x POLICY PR� LOC S AUTOM08i4E�wa�utr 1 000 000 ee a�aa„Z,_, s . . ANYAU70 BODILY WJURY(Per pe�aony S A AUT45 NE.O AU E�OULED M1T2386U �I7I2417 8I7IZOZH � � 60DILY INJURY(Per eccident� $ N6N•OWNEO Per ecctden S MIFED AU7p5 AU� $ un�eflEiLn LIAB X p�CUA EACH OGGURRENCE s 2�O O O, O O Q A EXCES6 LIAB 48SSANX5037 a/5/2017 4/5/2018 CIAIMS�MA�E AQGREGATE S �� O O O,O O O r.zQvoR LZAa DED �RETENTIdN S � WdRKERS COMPENSAT� rAn�• on+ ANO EMPLOYEqS'LW81LfTY 7ORYLI . . � . . M1Y pqOPqIEYfS1VPARTNFNf%ECUi1VE vQ bB�ECCM3443 4/1/2017 G/1J2Q18 E.LEACHACCIDENr s rJd�, �� A pFi10E1LU!EMBEH EXCl1AED7 N!A . . (M�nd�taryb Wq 6.1.4�SEA5E-E/t EMPLOYE S 500� a�� Y1�describe under oES�R�PnON FQPEfiA110WSbelow E.I.DiSEASE-POL1G�l�� & 500, 000 A UMBRELLA 0838ANX5037 4/5/2017 4/5/2018 Q, 000,000 DESCRIPTION OF pPEFATIQN$J t,QCAT16N5!VEHICLES �Auecn ACORD to1,Additrone�Reme�ks Schetlule,n more epece le requhed} RE�EIV�� OCT 2 5 2017 HEALTH DEPT. CERTIFICATE HOLDER CANCEI�LAT� N SHOULD ANr OF THE ABOVE DESCRIBEO PO�ICIES 8E CANC�LLED BEFpRE TOWN OF YARMOUTH TH� EKPIRATION DATE THEREOF, N4TICE wlLl BE DEUVERED tN ACCORDANCE W ITH THE POLICY PROViSIONS. AUT}10RIZED REPRESENTA IVE � � �►1968•2010 ACORD CORPORATION. All rights re9erved. ACORD25�2010/45) The AGORd name and IoB�are Yegl6tered marks of ACORO