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Home My WebLink AboutApplication and WC TOWN:,OF YARMOUTH BOARD OF HEALTH APPLICATION�'OR LICENSE/PERMIT-2018 *Please complete form and attach all ne�cessary documents by Decen er 15 2017. Failure to do so will result in the return of your applicatton pac et. ESTABLISHMENT NAME: N v.J h'L�,c�ut�$�f�T�Cvdu�lf�l- TAX ID: � LOCATION ADDRESS: 525 Rci?�'E�S�L.fL�S�'��a{��2�toD T'EL.#: r't r'i�-�}rIG-l,os'��Z MAII,ING ADDRESS: �AaIE. . E-MAILADDRESS: B�' Lo2h ��EF�'E�IC✓b�]�1�-1-.C�,� OWNER NAME:�(j i�jAM N�LJ-�-� CORPORATION NAME(IF APPLICABLE): i�1e,�q�Y,,lL+. MANAGER'S NAME: 'in(;�l ia�n t��..lk TEL.#:5�-�Q�-3�l�r MAILINGADDRESS:��iC+�lg��"(��QQ►��.��ls�u+41,��► nz�lofl 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. m � 1.�/i� 2. � � �'� _ � � Pooi operators must list a miaumum o�two employees currernly certified in standard First Aid and Community o N � Cardiopulmonary Resuscitation(CPR�,having one certified employee on�premises at all times. Please list the � �, employees below and attach copies of�heir certifications to tlus form.The Health Department will not use past v � � years'rernrds. You mnst provide new copies and maintain a fde at your place of business. � � � 1.�1�A 2. 3 4. r�.,�;', FOOD PROTECTTON MANAGERS-CERTIF'ICATIONS: �� All food service establishments are rac;uired to have at Ieast one full-time employee who is certified as a Food Protection Manager,as defined in the State Sanitary Code for Food Sezvice Establishments, 105 CMR 590.000. �'- Please attach copies of certificatiott to this application. The A�Ith Department wilt not use past years'recorda. �' � You must provide aew copies and maiuntain a file at your establishment �*+� �.�1 a 2. � : PERSON IN CHARGE: �� Each food establishment must have at�east one Person In Charge(1'IC)on site during hours of operation. i. �l/A 2 � ALLERGEN CERTIF'ICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in tlie State Sanitary Code for Food Service Fstablishments,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�'ile at your establishmen� 1. �E�L��ACI�E� 2. HEIMLICH CERTIE'ICATIONS: 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 misintain a 51e at yoar place of business. 1. /J�f�1 2. 3. 4• RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN S55 MOTEL SI10 —INN $55 —CAMP ' S55 SWIMMING POOL S110ea LODGE S55 _TRAILERPARK $105 _WHIRLPOOL $li0ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE RE�UIRED FEE PERMIT# 0-1{)0 SEA'1'S 5125 _CONTINENfAL S35 NON-PRO IT $30 >100 SEATS 5200 COMMON VIC. $60 �HOLESALE S80 — —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTf# <50sq ft�. S50 >25,000 ft. 5285 VENDING-FOOD S25 �QS,UWsq.ft. 5150 �� —FROZEN�ESSERT$40 �1'OBACCO SI10 NAME CHANGE: SI S AMOUNT DUE _ $ �r'JO-OO r•**'pLEASE T[�tN OVER AND COMPLETE OTHER SIDE OF FORM**�*' 0��/1^�OC�2� � �� tJ � ADNIINISTRATTON 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 oper�te a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATIUN INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CER�'.OF INSURANCE ATTACHED_� OR � WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid priar to ret►ewal or issuance of your peimits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS Al'�1D OTHER L�DGING ESTABLISIiMENTS TRANSIENT OCCUPANCY: For pwrposes of the limitations of Motel ar Hotel use,Tzansient occupancy shall be . limited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient cecupants must have and be able to demonstrate that they maitttain a principal place of residence elsewhere.Transient occupancy shall generally refer to coirtinuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(9(})days within any si�{6)month period. Use of a guest unit as a residence or dwelling unit sha11 not be considered Uransient 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 inspacted hy the Health Department prior to opening. Contact the Health p ent to schedule the inspection three(3) days prior to opeaing.PLEASE NO"�E:People are NOT a1low�ed to sit in the pool area until the pool k�as been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total caliform and standard plate count b�y�a�certified lab,and submitted to the Health Department three(3)days prior to opening,and quarterly POOL Ci.OSING:Every outdoor in ground swimming pool must be drained or covered within seven('7}days of closing. FOOD SER'VICE SEASONAL FOOD 5ERVICE OP�NING: 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 Yazmouth Health Depariment by filing the required Temporary Food Service Ap�plication form 72 hours prior to the catezed event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Heaith Departrnent, Downloadable Forms. . FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to openi.ng and monthly tbereafter,with sample results submitted to the Health Department. Faiture 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 seaUing with waiter/waih�ess service),mvst have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED RENEW.AL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATTONS TO ANY FQOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlv1'ING, NEW EQUIPMENTt ETC.},MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEAI.TH PRrtOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: {of��^ SIG1r7AT[JRE: �—_,,,�— PRINT NAME&T1TZE: �i 1��AiYI 1�� 'i pR��, r�" ��+�'/3�.d� x�.tonvt� '`��R�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDMIYY) 05/10/2017 THIS CERTIFICATE IS ISSUED AS A MA'tTER dF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH1S CERTIFICATE DOES NOT AFFIRMATIVE�Y OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT COIdSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcate hoider is an ADDITIONAL INSURED,the policy(les)must have ADDlTIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the ter►ns and conditions of the policy,certain policies may require an endorsemerrt. A statement on this certeflcate does rtot confer rights to the certificate hofder in tieu of auch endorsement s). PRODUCER C ACT Dianna Tubenrille MAME: PHONE . 2O5 26Z-27O0 Go S.S.Nesbitt 8�Company t ) � N,; (205)262-2701 3500 Blue Lake Dr.#120 E.MAIL ADDRES3: Birmingham,AL SSZ43 INSURER S AFFORDING COVERAGE NA{C# iNsuReRn:American Zurich Insurance Com an 40142 INSURED HR Service Group,LLC �nsueErt B: 3905 Nationai�r.Suite 400 INSURER c: Burtonsviile,MO 20866 INSURER D: INSURER E• INSURER F: COVERAGES CERTIFICATE NUMBER:17MD507938075 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE FOR THE POLICY PERIO� INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAlN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEF2EIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND C�NDIT�ONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEd BY PAID CIAIMS. INSR A SUBR POUCY EFF POLICY p(P TR TYPEOFINSURANCE POLICYNUMBER MMIDD MMfD LIMRS COMMERCULL GENERAL LWBIUTY EACH OCCURRENCE $ GLAIMS-MADE �OCCUR DAMA E TO N D � PREMISES Ea occurrer�ce $ MED EXP(My one person) $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑jE a �LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILfTY COMBINED SINGLE LIMIT � ANY AUTO Ea acddent BODILY INJURY(Per persan) $ OWNEO SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ E%CE33 LtA6 CtAIMS-MADE AGGREGATE $ DED REfENT10N $ WORKERS COMPENSATION AND EMPLOYERS'LIABtLRY Y�N X STATUTE ,. ERH _ A OA�CERI EM�EX�C uL oEo�cunve Q N�A WC01-10-480-01 05/01/2097 05l01/2018 E.L.EACHACCIDENT s 1000000 (Maodatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000 OOO If yes,describa under DESCRIPTION OF OPERATIONS bebw E.l.DISEASE-PO�ICY LIMIT $ 1,000,000 Location Coverage Period: 05/01/2017 05/01/2018 Clierrtt# 0385-MA DESCRIPTION OF OPERAT10N3/LDCATIONS/VEHICLES(ACORD 101,Addkionai Remarks 3chedula,may be attachad H more apace is required) coverage�s provided for Hunta inc dba:Beef Jerky OuUet o„iy�� 525 Route 28 of.but not autwntractora �►est Yarmouth,AAp,02673 ta: CERTIFICATE HOLDER CANCELLATION Hunta Inc SHOULb ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE dba:Beef Jerky Outlet THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 525 Route 28 ACCORDANCE W1TH THE POLtCY PROVISIOMS. WBSt Y8ffTlpUtI1,MA 026T3 AUTHORIZEDREPRESENTATNE V ��,W/""'..`'' .., ... ' 01988-2015 ACORD CORPORATION. Ail rights reserved. ACORD 25 l2016/031 The ACORD name and loao are reaistered marks of ACORD