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Home My WebLink AboutApplication and WC� _.._� � � TOWN OF YARMOUTH BOARD OF IiEALTH - ��lV +J$ �'O i� i APPLICATION FOR LICENSE/PE � � �8 �, � � ` * Please complete form and attach all neeessary d�4 e �� _._�:�� Failure to tio so will result in the return of your applica.tion pac cet. `� ESTABLTSHMENT NAME: LOCATION ADDRESS: 1 -� TEL.#: 6�' 7 7/- �7�,� MAILING ADDRESS: �t,nn-� � E-MAII,ADDRESS: VU.VI�'�'1Gvl�Yiln��' ��f�-�-Q.u.rG�� C:tPr1A.�( . G�►�l OWNER NAME: CORPORA7TON NAME A.PPLIC.�IBLE): (',��aty�d.,r � �r►� MANAGER'S NAME; Vt\[��✓� vp TEL.#: MAILING ADDRESS: Sat.m-�' POOL CERTIFICATIONS: The pooi 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 operaxors must list a minimum of two emplayees currently certified in standard First Aid and Cammunity Cardiopulmonary Resuscitation (CPR�, having one certified employes on premises at a11 times. Please list the employees below and attach copies of their certifications to this farm.l'he Health Department will not use past years' records. You must provide new copies and maintain a file at yaur place of bnsiness. l. 2. 3. 4. FOOD PROTECTION MANAGERS=CERTIFICATIOl'�TS: All food service establishments are required to have at l�east one full-time employee who is certified as a Food Protection Manager, as defined in the �tate Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to t�iis application. T6e Health Department wi11 not use past years'records. You must provide new capies and maintain a f le at y�ur establishment. �.� r�� 2. PERSON IN CHARGE: Each food establishment must have at least one Person Iix Charge(PIC)on site during hours of operation. a 1. t Y:1� 2. ALLERGEN CERTIFICATIONS: ` All food service establishments aze required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Esta.blishments, 105 CMR 590.OQ9(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You mnst provide new copies and maintain a file at your establishmen� 1�.Yl <�],�l.(V� � ' 2 HEIlVILICH CERTIFICATIONS� A�l 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 ernployees trained in anti-chokuig 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. �,vun e� �s 2. Chr�Skc�.s � 3. 4. RESTAURANT SEATIl�TG: TOTAL# ' OFFfCE USE ONLY . LODGINGc LICENSE REQUIRED FEE PERMIT# :LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEB PERMIT# BBcB $55 CABIN $55 MOTEL $110 —INN $55 CAMP $55 SWIMriIING POOL�l l0ea. _LODGE S55 TRAILER PARK �105 _WHIRLPOQL �I l0ea. FOOD SERVICE: LICENSE RE�UIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-IQO SEA S �125 �q CONTINENTAL S35 NON-PROFIT $30 �>100 SEATS �200 ��1 �COMMON VIC. S6U �3 WHOLESALE S80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ZICENSE REQUIRED FEE PERMIT#. LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 >25,Q00sq ft. �285 VENDING-FOOD $25 =QS,000 sq.ft. $150 ��FROZEN DESSER'� �40 _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE _ $ ?100.0� *****PLEASE TURN OVER AND COM�LETE OTHER SIDE OF FORM***** �vo��-L�-��,�.�a� � ADNIINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town af Yanmouth 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 WURKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLET,'ED AND SIGNED,OR CERT. OF INSURANCE ATTACHED � OR . WORKER'S C011vIP.AFFIDAVIT�IGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to ne�ewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS APiTD OTI�R LOD�GING ESTABLISHMENTS TRANSIENT OCCUPANCY: For ptiirposes of the limitations of Motel or Hotel use,Transient occupancy shall be Iimited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must ha.ve and b� able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall g�nerally 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 ttansient. Occuparicy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L. c. 64G or;830 CMR 64G,as amended,sha11 generally be considered Transient. POQLS POOL OPENING.All swimming,waiiing and whirlpools which have been closed for the season must be inspected by the Health Department prior to operiing. Contact the I-�ealth Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: Peopte are NOT allawed 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 De�artment three (3) days prior to opening, and quarterly therea.fter. POOL CLOS�NG:Every outdoor in g�aund swimming pool must be rlrained or covered within seven(7)da.ys of closing. ! FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior#o opening. Please contact the Health Department to schedule the inspection three(3)days prior to opening. CATERING PQLICY: � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form ?2 �iours prior to the catered even� These forms can be obtained at the He la tb.Department,or fnom the Town's we�site at www.yarmouth.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 samgle results submitted to the Healfh Department. �'ailure 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 CUOKING: Outdoor cooking,preparation,or display of any food product by a z�etail or faod service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR.RESPONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APP�,TCATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOIOD ESTABLISHMENT, M4TEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.},MUST BE REPI�RTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ, SIT� N. , �. DATE• I� � � I 1'� SIGNATURE: �'"� PRINT NAME&TITLE: Yl Rev.10/12/17 Client#:22600 2DIPARMA ACORD.M CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 10/05/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THI3 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 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 dces not confer rights to the certificate holder in lieu of such endorsement(s). pRppUCER NTA NAME: Dowling&O'Neil Insurance Agy ac"o EXt:508 775-1620 F /uc No: 5087781218 973 lyannough Road E-MAIL P.O.Box 1990 ADDRES3: INSURER(S)AFFORDING COVERAGE NAIC# ' Hyannis,MA 02601 INSURER A:Gu+rd in+uranm�ro�p 42390 INSURED INSURER B:Norcusrd�nsuronn Company 31470 Calamari,Inc DBA DiParma Italian Table A/O Tasty Tidbits Realty Trust iwsur�c: INSURER D: 175 Main Street INSURER E: West Yarmouth, MA 02673 INSURER F: 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. NOTWITHSTANDING 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE ��SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICYNUMBER MM/DDNYYY MMIDD LIMITS A GENERAL LIABIL�TY CABP844473 6/15/2017 06/75/201 EACH OCCURRENCE $� �� X COMMERCIAL GENERAL LIABILITY DAMA�,E T RENTED PREMISES Eaoa:urrsnce $SO OOO CLAIMS-MADE �OCCUR MED EXP(Any one person) $rJ,�� PERSONAL&ADV INJURY $��OOO�OOO GENERALAGGREGATE $Z,OOO�OOO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $��OOO�OOO � POLICY P CT LOC $ � ! AUTOb1061LE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILYINJURY Peraccident $ AUTOS AUTOS ( ) NON-0WNED PROPERTY DAMAGE HIREDAUTOS AUTOS Peracadant $ I $ � UMBRELIA LIAB OCCUR EACH OCCURRENCE $ � EXCESS LIAB CLAIMS-MADE AGGREGATE $ � DED RE7ENTION$ g B WORKERSCOMPENSATION CAWC857256 6/01/2017 06/01/201 X wCSTATU- OTH- AND EMPLOYERS'LIABILITY �� ICEWMEM ER XCLUDED?ECUTIVE� N,A E.L.EACHACCIDENT $SOO OOO � (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $SOO�OOO If yes,describe under DESCRIPTION OF OPERA710NS below E.L.DISEASE-POLICY LIMIT $rJOO�OOO A Liquor Liability CABP844473 6/15/2017 06/75/201 $1,000,000 per occ. $2,000,000 aggregate DESCRIPTION OF OPERATIONS/LOCATION31 VFJiICLE3(Attach ACORD 101,Additlonal Remarlts Schedule,If more apace Is requlred) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions.Members are included under the workers compensation policy. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Board of Health ACCORDANCE WRH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 AUTHORIZED REPRE3ENTATIVE �..,.� 4�� , OO 1988-2070 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 2 The ACORD name and logo are registered marks of ACORD #S198990/M198983 LS1