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Home My WebLink AboutApplication and WC, �► TOWN`OF YA.RMOUTH BOARD OF HEALTH APPLIGATION�OR LICENSE/PERMIT-2018 �" *Please complete form and attach all necessary documents by December IS 2017. Failure to do so will result in the return of your applicahon pac cet. � ESTABLISFIlv1ENT NAME: LOCATION ADDRESS:�S�� RD(JT� S TEL.#: MAILING ADDRESS: .SA�1� E-MAII,ADDRESS: �C IZ !_.. '/ T�S'P l/L.IT�S. �O NL OWNER NAME: � 2- CORPORATION NAME(IF PLIC,ABLE): / P/R-tT MANAGER'S NAME: /�- L N c TEL.#: I '�,�j�j S MAII,ING ADDRESS: O� lS G?��a3g POOL CERTIFICATIONS: The pool snpervisor must be certified$s a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certifica.tion to tlus form. 1. 2. m � .�D D —�-� t�'7 Pool.operators must list a minimum of two employees currendy certified in standard First A.id and Community —rj •v n Cardiopulmonary Resuscitation(CPR�,having one certified emmployee onprem�ses at all times. Please list the = �..� E'T1 employees below and attach copies of their cerhfications to this form.The Health Department will not use past O ,�� years'records. You must provide new copies and maintain a file at your place of business. .m :+ � -1 ``i � 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIF'ICATIONS: All food service establishments are re+quired to have at least one full-time employee who is certified as a Food �?� Protection 1Vlanager,as defined in the State Sanitary Code for Pood Service Establishments, 105 CMR 590.000. ' Please attach copies of certification to ttus application. The Health Department will not use past years'records. � �� You must provide new copies and maintain a file at your establishment � 1. 2. � � � O r-. PERSON IN CHARGE: Each food establishment must have at least one Peison In Char$e(PIC}on site during hours of operation. .�' 1. 2. � ALLERGEN CERTTFICATIONS: All food service establishments are required to have ax least one fiull-time employee who has Allergen certification, as defined in the State Sanitsry Code for Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will nof use past years'records. You must prnvide nevv copies and maintain a Sle at your eatablishment. 1. 2. HEIl�ILICH CERTIFICATTONS: 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 ami-cholang procedures below and attach copies of employee certifications to this form. The Health Deparhnent will not use past years'records. You must provide new copies and m�intain a file at your place of business. 1. 2. 3. 4. RESTAUKANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# B8cB $55 CABIN $55 MOTEL $110 —ITIN $55 —CAMP S55 �SWIMIvIING POOL S110ea. _I.ODGE $SS = RAILER PARK $105 _WHIRLPOOL E110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERIvfIT# LICENSE REQUII2ED FEE PERMIT# _0-100 SEATS 5125 _CON7INENTAi, S35 NON-PROFIT E30 C �( �� >]00 SEATS 5200 _COMMON VIC. S60 WHOLESALE aso �pNF��7�`�'pZj =RESID.KITCHEN S80 RETeVL SERVICE: RMI� L+C��E RftEQUIRED a O P # LI'2 S�Q�UIRED $285 PERMIT# LICEENDI�NG FooD� PExA•nT# p _�s.o�o' �,.�. aiso � �oL �RdZEN�ESSERT S40 =TOBACCO E110 � p,��..��'��/�2 �� NAME CBAIYGE: S15 AMOUNT DITE _ $��p,�y *"*•;PLEASE TURN OVEB AND COMPLETE OTHER SIDE OF FORM***'�* ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the TovVn 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 AITACHED STATE WORI�R'S COMPENSATION INSURANCE AFFIDAVI'T MUST BE COMPLETED AND SIGNED,OR CERT.OF INSUR4NCE ATTACHED OR WORKER'S COIVIP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK APPROPRIATELY IF PAID: YES NC? MOTELS A1uD OTHER LODGING ESTABLISHMENTS TRANSIENT OCCiJPANCY: 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#lvrty(30)days,and an aggregate of not more than ninety(9�)days within auy six(6)month period. Use of a guest unit as a residence or . dwelling unit shall not be considcred transien� Occupancy that is subject to the collection of Room Occupancy Fa�cise,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 ciosed for the season must be inspected by the Health Department prior to opemng. Contact the Health Department to schedule the inspection t6ree(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 snbmitted 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 ciosing. FOrOD 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 opemng. CATERING POLICY: ` Anyone who caters withix►the Town of Yarmouth must notify the Yarmouth Health Department by filing the requized Temporary Food Service Application form 72 hours prior to the catered even� These forms c,an be obtained at the Hea.lth Department,or fiom the Town's website at www.yarmouth.ma.us under Health Deparl:ment, 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 vrnll result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOI�NG: Outdoor cooking,prepara#ion,or displary 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 15,2017. Ai•T• RENOVATIONS TO ANY FOOD ESTABLISHIvIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRfOR TO CONII�NCEMENT. RENOVA7TONS MAY UIRE A PL . 'i/�,� - DATE: �U r/7 y�7 SIGNAT'[JRE: �� rRn�rr NaME��t�ri.E:Cf�F � N �J �CA!2�" PR.�1 D�NT xeV.ionvn �""�'� OP ID:AD '`��R�"n CERTIFICATE OF LIABILITY INSURANCE DATE{MMlDD/YYYYj 10126/2017 THIS CERTtFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RICiHT3 UPON THE CER7IFICATE HOLDER.THI3 CERIIFICATE DOES NOT AFFIRMATiVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONS7ITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S�, AUTHORI2ED REPRESENTA7IVE OR PRODUCER,AND THE CER7IFICATE HOLdER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,su6ject to the terms and condPtions of the pollcy,certain policies may requlre an�dorsement. A statement on this certi8cate does not confer ri�ts to the certiflcate holder In Ileu of such endorsement s PRODUCER WM.F.Borhek Insurance Agency �4� F 37 7 Plymouth Street C No E : AlC No: Halifax,MA 02338 E�A�� 5cott C Cas�rande aoor�ss: cusTOMeR io�:BECKE-1 INSURE S AFFORDING CpVERAGE NAIC/ � INSURED BeckersPackag¢Store ,n�Ra:GreatAmericanlns.Co. 55 Route 28 �r,sur�R s:Massachusetts Retail Merchants West Yarmouth,MA 02673 INSUFtER C: INSURER�: INSIHtER E: � INSIJRER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POL�IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABONE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WfTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMffS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � T'PE OF INSURANCE POLICY NUMBER M ID M!� L�� CsENERALLIABILITY EACHOCCURRENCE $ 'I,OOO,OQ A X COMMERCIAL�GENERALLIABILITY SPP1565178 �0/Z�/2�� 10121/2078 pREMISES Eaoccurrence $ 300, CIAIMSMADE �OCCUR MED EXP{My one person) $ �O,OO X BUSI0888 QW�18(S PERSONAL&ADV INJURY $ 'I�OOO�OO GENERAL AGGREGATE $ Z,OOQ, GEN'L AGGREGATE LIMIT APPLIES PER: . PRODUCTS-COMP/OP AGG $ Z�OOO, X POLICY PR�- LOC IQUOR $ S1MILls2Ml AUTOMOBILE LU4BILITY COMBINED SINGLE LIMIT $ �,OOO,O (Ea accidenp ANY AUTO � BODILY INJURY(Per person) $ ALL OWNEDAUTOS BODILY IN,HJRY{Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS SPP7565178 10121IZ077 10/Y1/YO'IH (PER ACCIDENT) $ X NON-OWNEDAUTOS $ $ ��8��B OCCUR EACH OCCURRENCE $ EXCE33 LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBIE S RETENTION S $ WORKER3 COMPENSATION X WC STATU- OTH- AI�EMPLOYERS'WIBILITY TORY LIMITS ER B ANY PROPRIETOR�PARTNERIEXECUTIVE Y I N 140005023031 �'I101l2417 01I071207$ E L EACH ACCIDENT $ �0�� OFFlCERIMEMBER EXCLUDED7 � N!A (MandaloryinNH) E.L.DISEASE-EAEMPLOYEE S 100,0 ifyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOO�OO q Property SPP75651T8 70121l2017 10I21I2078 PROPERTY 110,0 DESCRIPTI6N OF OPH2ATON3!LOCAT10N3!VEHCLES{Attach ACORD 107,Additlonal Remarka Sehs�a,If moro spus ts rsqulrodJ � • Store Location: 55 Route 23,W.Yarmouth,MA 02673 CERTIFICATE HOLDER CANCELLATION TOWNYAR � �1QULD ANY OF iHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH TM� EXPIRATION DATE 7HEREOF, N0710E WILL BE DELIVERED IN ACCORDANCE WIT1i 7HE POLICY PROVISIONS. 1146 MAIN STREET.RTE.28 S.YARMOUTH,MA 02663 aurHa�zeor�rr�sEnrrarne Scott C Casagrande O 1868-2009 ACORD CORPORATION. All rights reserved. ACORD 25(20Q8/09) The ACORD name and logo are registered marks of ACORD