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Home My WebLink AboutApplication and WCI � � � � � �� - � TOWN OF Y�RMOUTH BOARD OF HEALTH (� � C .--t� �- APPLICATION FOR LICENSE/PERMIT -2018 * Please complete form and attach all necessary documents by December 1 S. 2017. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: � �' T ID: . ,�' LOCATION ADDRESS: G TEL.#: 57,� G S�va� MAILING ADDRESS: o / ti, r �,,- E-MAIL ADDRESS: " �i q�'S" � 6 r Cca/� � � �=;� " � OWNER NAME: � c �r � ; � , CORPORATION NAME(IF APPLICABLE): �n�-�l /� � C,r`��S Z'ru C � � - �'�' MANAGER'SNAME: C � C.�Je e TEL.#: � �{�7 /G7� MAILING ADDRESS: r�� o �. � � � � POOL CERTIFICATIONS: {��v q �7 ' The pool supervisor must be certified as a Pool Operat,or,as required by State law. Ple e li§�`the�L�s��(ted � Pool Operator(s)and attach a copy of the certification to this form. �,�,,, . , , ^�T � 1. 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. 2: � PERSON 1N CHARGE: � Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��c�� -� 4� c, � 2. � e�r�� wU) c'A� � , ��-s' � 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 far 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: A11 food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ' 1Vlaneuver on the premises at all times. Please list your employees trained in anti-chaking 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 LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIIvIMING POOL$I l0ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE R IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,�0-100 SEATS $125 ��-0_34 _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 <25,000sq.ft. $150 _FROZENDESSERT $40 TOBACCO $110 NAME C�IANGE: $is AMOUNT DUE _ $ C��e Uj� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** go�r--�s-�bz�-o3 i � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal � of eny license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACH�D 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 APPROPRIATELY IF PAID: / YES ✓ NO ' MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 OPElvING:�411 swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to opening. Contact the Health Deparhnent 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 pseudornonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Depaxtment 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 � elosing. ' ; FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Deparhnent prior to opening. Please conta.ct 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. Failwe 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. � E OUTDOOR COOKING: � 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 31. IT 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 THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE RE A SITE PLA . , / i DATE: I 1 ( �! f( � SIGNATURE: i PRINT NAME&TITLE: < �c,�.✓i € i , Rev. 10/12/17 � { � E -�'''� JAMES-2 '4�R�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YWY) 11/22/2017 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 certi�cate 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 508-775-6060 COME CT Hyannis O�ce Bryden 8 Sullivan Ins Agency PHONE 508-775-6060 FAX 508-790-1414 88 Falmouth Road nic,No,e��: �ac,No: Hyannis,MA 02607 noDR�E • Hyannis Office INSURER S AFFORDING COVERAGE NAIC# �n,suReR n:The Hartford 22357 uusuReo�ames A.liadis,Inc.DBA INSURER B: Black Sheep Bah 8 Grill 84 Rocky Ridge Road INSURER C: Dennis,MA 02638 INSURER D: INSURER E: INSURER F: C V RA E CERTIFICATE NUMBER: R VI I N 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 WITH 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, I! EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. { INSR TypE OP INSURANCE DDL UBR pOLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR PRMAGE T EaENTED $ MED EXP An one erson PERSONAL&ADV INJURY $ � GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY��E a � LOC PRODUCTS-COMP/OP AGG $ THER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY Per erson $ OWNED SCHEDUIED AUTOS ONLY AUTOS BODILY INJURY Peraccident $ � HIRED NON-p WNED PROPERTY DAMAGE i AUTOS ONLY AUTOS ONLY Per accident $ I UMBRELLA LIAB OCCUR EACH OCCURRENCE $ � EXCESS LIAB CLAIMS-MADE AGGREGATE . DED RETENTION$ A WORKERS COMPENSATION PER OTH- � AND EMPLOYERS'LIABILITY TA ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N OHWECCI64GB O$/OH/YO17 O3/O8/2O1H E.L.EACH ACCIDENT $ SOO�OOO QF�FICER/MEMBER EXCLUDED? � N�A SOO�OOO (Mandatory in NH) . E.L.DISEASE-EA EMPLOYEE $ If yes,describe under � D SCRIPTI N OF PERATIONS below .L.DI EAS -POLI Y�IMIT SOO,OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,Additional Remarks Schedule,may be attached if more space is required) . --- , �'--__-._-._._._Y. . . ? �Q� �' 7 �Lfli7 ; : � ' t.t - - �.,_,.�.�_ -_�_._._____,� ; CERTIFICATE HOLDER CANCELLATION TOWNYAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA710N DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE Hyannis Office ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD