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Home My WebLink AboutApplication and WCr ;., ` � � � a � ,.:� _.. ��.�-1--� � TOWN OF YARMOUTH BO �iA�� : . � APPLICATION FOR LICENS r - � x ,� NOV �9 20�� ,�- � �:. : * Please complete form and atta.ch all neces� m �-; � Failure to do so will result in the return of your application e�:="� � —� ESTABLTSHMENT NAME: !�L�"la�v 7`� !L� �,i �c v v ac�� TAX ID• LOCATION ADDRESS:___,5�/ K/ti'6s C'i v cvc �Y�'ov ti Yl�. �;�6�-,5 TEL.#: �:..�,� 3(,2 S�-�o c� MAILING ADDRESS:_�U f�C rNG S Cr2Li��°f ��t rL�i o�7� . �a�r7.- .,�/e�. c�2 G � � E-MAIL ADDRESS: l � , ) /L 17��tel�v//m �t�t% (� OWNER NAME: ,�ui"� ('x�L�� CORPORATION NAME IF APPLICABLE): /� 17Dac�7�F�� /,UC MANAGER'S NAME:�U[s C��L� . TEL.#: ��-�( .2 6� 1�c�o MAILINCr ADDRESS: �C{ !,r i irv�s C i`v r� �F ,%rz r c�o u fLi, P;,-f D�IA- D 2,5 ��, POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operat.or,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), havmg 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. �,vis <� fjP. 2: �r �� v1�- PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. � ��( 1 � l I P 2. ld p T�.,fc�ti' �F'1�r.��L�.L CC� � 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 for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please atta.ch ' copies of certification to this application. The Heatth Department will not use past years' records. You must ' provide new copies and maintain a file at your establishment. li i. ,��z� c�CL� 2. �� L A ��- �', HEIMLICH CERTIFICATIONS: �'i All 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-cholcing procedures below and � attach copies of employee certifications to this form. The Health Department will not use past years' records. 'i You must provide new copies and maintain a file at your place of business. !i 1. �r�Z S L',4 L G � 2. A N 1?e � Gi4 G L £ I�I 3. C �Z s T��N r'J4- � 4. ', RESTAURANT SEATING: TOTAL# / �� . OFFICE USE ONLY / LODGING: f LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED 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: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i 0-100 SEATS $125 �, CONTINENTAL $35 NON-PROFIT $30 =>100 SEATS $200 ��!�`e'�'✓ J—COMMON VIC. $60 ��Z� _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' <50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $I50 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $i s AMOUNT DUE _ $ 2�o O .-O O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** $o��-t�--�a5�-Ol � r � I , 1 6 Y � ADMINISTRATION � Under Cha ter 152 Section 25C Subsection 6 the Town of Yarmouth is now re uired to hold issuance or renewal � P , � , q 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 ATTACH�D STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR � i CERT. OF INSURANCE ATTACHED OR , WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth tazces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ' / ; YES V 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 sha11 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 sha11 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 Tra.nsient. POOLS ; POOL OPENING:�11 swimming,wading and whirlpools which haue been closed for 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 aze NOT allowed to sit in the pool area until the pool has been � inspected and opened. . i ; POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count I 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 j elosing. ! 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 mus� notify the Yarmouth Health Department by filing the j 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.parmouth.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 COOKING: ! Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' � j NO'�'ICE: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 REQUIRE A SITE PLAN. ; DATE: �/- q - J �- . SIGNATURE: ��L}-=- �"�,� ! t PRINT NAME&TITLE: L vs� .4. ��LL f /�l �►-Pf A- �� I � Rev. 10/12/17 � i i � ; ' � �►�o o' � CERTIFICATE OF LlABILITY iNSURANCE �,,,`�' i TNIS CERTiFiCATE �8 ISSUED /18 A MATTER OF 1NFOF�MATION ONLY AND CONFERS NO RIGHT8 UPON TNE CERTfFiCATE HOLDER.THIS CERTIFICATE DOLS NOT AFFIRMATIVELY OR MEtiA'RVELY AMEND, EXTEND OR ALTER TFiE COVERA�iE AFfORDED 8Y Tt1E POLICIES gE1.pW. TWIS CEI'tTIFiCATE � INSURANCE DOES NOT CONSTITUTE A CONTR/lCT BETWEEN THE ISSUINO {N8URER(8), AUTHORIZED REPtiESENTI►TIYE OR PRODUCER,AND THE CERTtF1CATE HOLDER. IMPORTANT: H fhs prtMc�h hoidK b u� ADDIi10NAL INStIt�. tl�s PdiayA�} must b�rndwsed. H 8UBROGATION IS WAIVED, wh�to u� tha t�nns and cond(tlaa o(ffio pol�r,outain Po�s maN nqutn an e�o►�� A stabmsnt on 1Ms esrtltk�s dws not conter d�b to the a�rt�e hdd�in llw at suefi�ndon�t(s} � atmn«te7s)as�-�Fa�c (e�e5l�eea �!'�T SullH►att ttuurance AA�Y SULWAN INSUR/WCE AGENCY pHO11E 8 SS1-9600 "X (8T8)851-4848 883 MAIN Si'RELT c-� • TEWlCSBURY MA 01876 ��p �E wuc r uiau�n : Scottsdale Insurmos CanQeny . �r�,�Re : MA Retalt M�rr.hartts Work�rs Comp aroup i.L.MONTEBELLO INC. 6414NOS WAY orsurm+c : 8coitsdale Insuranc�Com YAI�AWJTHPORT MA Q287S �o: INBURER E : INBURlR F : CpyERppES CERTIFICATE NUMBER: 27286 REVI810N NUMBER: THI3 IS TO CERTIFY THAT THE POUC�S OF INSURANCE LISTED BELOW HAVE BEEN lSSUED TO THE IN3URED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWRHSTANDiNCi ANY REQUIREMENT, TERN► OR CONDITION OF ANY fiANTRACT OR OTIiER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFlCATE MAY BE ISSUED OR MAY PERTAItd, THE INSURANCE AFFORDED 8Y TFfE POLlC1ES DE3CRlBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCL SIONS AND CONDR OF .LIM SH N MNY HAVE B ��0 �•� � TYPE�WEURIUICE � � �'�� $ A � � CP�2250i27 Q1/ZO%IT 01/�!'IS ��cut�eE S 1.00O,Q00 NMMERCUIL t3ENERAL W4BILITY P�Es 000uara� S St1�0� q�� ❑X OCCUFt MED.FXP U�Y�P�) S 5��0 �Rsaw►�&aov u�ru�v i 1�000.�0 ��,.,�o�o�� a 2,000,000 O�'L Roo�on7F uMR n�xie6�: �rt�u�rs-con�roP aaG S 1,000,�0 POLICY �a L� $ c�reu�o auro�ue�nr $ � �y t�.� BODILY INdURY(Pw pwaon) 8 �� SGHEDIA.Es BQDItY INdURY(Per�ddant) $ AUTOS ��p i HfRED NJTOB �T� S � X � ,�,. 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