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Home My WebLink AboutApplication and WC; � � � � �� . - � � � k j _ . ..,_. ..�� . .:v � .,_.� _ ..:.... � � TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICENSE - . �� ` ; �� f 3 z Q j 7 ' � �. i * Please complete form and attach all necess °'" �o t3� �' ber �^ �;-.� =,- � Failure to do so will result in the ret��of �p��a a . �- rv .' ESTABLISHMENT NAME: ' S T ID• LOCATION ADDRESS: TEL.#• � MAILING ADDRESS: a E-MAIL ADDRESS: OWNER NAME: c. V � k�a. CORPORATION NAME(IF APPL LE): MAl�AGER'S NAME: h�c� TEL.#: - lool-- �'-� MAILING ADDRESS: ,� 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 atta.ch 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), hav' ertified employee on premises at all times. Please list the employees below and attach copies ir certifications to this form.The Health Department will not use past years' records. You must ide 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 fde at your establishment. I 1. 2; i � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. �1. �, ��.�a� _ 2. _ _ __ ___ _ , � � ALLERGEN CERTIFICATIONS: i 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 attach i copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a fde at your establishment. 1. 2, HEIMLICH CERTIFICATIONS: 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-chalcing procedures below and attach copies of employee certifications to this form. The Health Department will not use past ears' records. Y You must provide new copies and maintain a file at your place of business. l.,f'� 'd�-� ��a.�� -�,,,� 2. 3. 4, RESTAURANT SEATING: TOTAL# -- — ----- -- _ _ _ _--- OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOT'EL $110 INN $55 CAMP $55 SWIMMING POOL$1 l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 (g-0�I',� CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 �Z _WHOLESALE $80 ' —RESID.KITCHEN $8U ' 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. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $is AMOUNT DUE = $ ��.Q� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �j��"'��—b�jlg—��' f i L . , , ADMINISTRATION ' , � 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 operate a business if a person or company does not have a Certificate of Worker's '� � Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR i 4 � CERT. OF INSURANCE ATTACHED ; OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED f ; Town of Yarmouth taxes and liens must be paid prior renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: , YES , NO MOTELS AND OTHER LODGING ESTABLISHMENTS I 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 ux�it as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to tlie 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 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 pseudomonas,total coliform and standard plate count 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 ` elosing. ' _ _ _ __ � . , _. - . FOOD SERVICE ; r 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 eaters within the Town of Yarmouth mus� 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 Depariment,or from the Town's website at www.yarmouth.ma.us under Health Department, i Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and rnonthly 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 Boazd of Health. OUTDOOR COOKING: I Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. M NO�ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN E 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 f EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COM N MENT. RENOVATIONS MAY REQUIRE A SITE PL N. ` � DATE: SIGNATURE: _ PRINT NAME& TITLE: � Rev.10/12/17 ' I � '� i I � � Ac Rt� CERTIFICATE OF LIABILITY INSURANCE °"�`'�'°°m""' � 10/1?l2017 �Thl$CERTIFICATE IS IS3UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFiCATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AIMEND, EXTEND OR ALTER THE GOVERAGE AF�ORdED t3Y THE PdLIC1E3 BELOW. TH13 CERTIFIGATE OF INSURANCE DOES NOT CONSTtTUTE A CONTRACT BETWEEN THE tSSUiN(3 IN8URER(S),AUTHORIZED REPRE3ENTATNE OR PRODUCER,AND THE CERTIFlCATE HOLDER. IM R AN7:If the csrtiflcate holder is an ADDITIONAL INSURED,the poltcy{t�)must be endorsed.If SUBROGATION IS WAIYED,subJect to tt�e terms and conditions ot tha palicy,certain policieg rr�ay require an endorsemer�.A staternent on thls certificate does nat corifer rights to#�e certlficate haider in ileu of such endorsemeM(s). P�ER NAME. AutanaNc Data Processing lnsurancs Agency,inc. �E Arc �: 1 Adp Boulevard ,� Roseland,NJ O7QB8 lasuREtt�s)a��Ht3 c�vEt�naE nwG s a�r�a: �Oy��'��w►a^��r 10346 i nrauR�ar - _ �+sur�t s: tNAHO JAPANESE RE8TAURANT ��a�re c: 157 RTE 6A I Yatn�oudtport,MA 0�76 ��: j e+��t e: 1NStIRBR F: COYERAGES CERTiFlCATE NUMBER: 761091 REYISION NUMBER; THiS!3 TO CERFIFY THAT THE POUCl�$OF INSURANCE USTED BELOW HAYE BEEN ISSUED TO THE INSURED NAMED ABQVE FOR 7HE PQLICY PERIbD IN�ICATED.PIOTWlTHSTANDlNG ANY REQWREMENT,TERM OR G4NDITION OF ANY CONTRACT OR OTHER DOCUMENT VM'T'H RESPECT TO WHICH 7HIS , CERTIFiCATE MAY BE ISSUED OR MAY PERTAIN, TI�E�fFtSURA1NCE AfFORDEO BY THE POLICIES DESGRIBED HEREtN IS SUBJECT TO ALL THE TERMS, � USIONS AND CONDfTiONS OF 3UCH POLICIES.LIMITS SHOWN MAY liAVE BEEN REDUGED BY PAIO CLAIMS. � TYP�Of�tlRANCE POL�CY NUiMBER 11 N�11D LJMIT8 COMMERCtAL GLNgRAI LIABiLM EACH OCCURRENCE S CU1IM3-AAADE �OCCUR PREMISE3 a S IeIED EXP(MS+�e Perea�) S PERSONAL&p�QV INJURY S GEML AGGRECiATE lNatiT APPUE3 PER: GENERAL AGGREGATE S pOLICY❑JEC �lOC PRODUCTS-C AGG S OTHER: t auroNroe��e un�urr �a s /WY AUTO BODILY lNJURY(Per persortj $ ALL OWNED SCHEDULED AUT'03 AUTO$ BODILY INJURY(Per aecident) $ HIR,ED AUTOS �p�E� PR� E� A 3 S �� EACH OCCURRENCE $ BXCpS UAB CLAIMS�MDE < AGGREGATE ; DED RETENTION S � S YYORKSRS COMPENEAI'10�1 x ANG EMP�"GYERB'WBlUTY TE ER A ANY PR�PR�E�QR/�q�TNER�XECUT�VE Y/N E.L.EACH ACCIDENT s �r��,�Q �FiCERIMEAA�R EXCLUOED4 �N f A N EIG?Ag66860Q 05�02/201T �$��Z/�$ ryy�� N�� E.l.DISEASE-EA EMPLOYE $ �,DOO,� DE$G�R�TI�ON OF OPERATI�NS bebw E.L.DiSEASE-POLtCY LIMIT $ 'I.OaO,OOO ! a! oEsc�PnoN a�oP�amoNs�wcanoHs r vp�rc�s�AcoRu�oi,admnonai Ranancs ae�eawa,may ne saaenad K mae syace�s reyu�recq CERTIFlCATE HOLDER - CANCELLA'fION SHOULD ANY OF THE ABOVE[�SCRIBED POLIClES 8E CANCELIED BEFORE THE EXPIRATION DATE THEREOF, NBTICE WILL BE DEtIVERED IN Town of Yartnouth ACCORDANCE WITH 7HE POLICY PROVISiON3. 1146 MA-2$ SOUN1 Y8fl110UtFt�MA OZB$4 AUTHORIZED REPRESENTATNE �� 1988-2014 ACORD GORPORATION.AII rights reserved. 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