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Home My WebLink AboutApplication and WC� � ', ��a TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR 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 applicatton pac et. ; ESTABLISHMENT NAME: �t9 �A" l�l �t.' T I • - i LOCATION ADDRESS: 1 C�C Wi� �`'�E TEL.#: `� '�GG.3 MAILING ADDRESS: E-MAIL ADDRESS: K�Z�S O F� M� � - � OWNER NAME: �D I�t��SO CORPORATION NAME(IF APPLICABLE): r Ai l9� i• � MANAGER'S NAME: /� ET l�C- I � TEL.#: MAILING ADDRESS: � (� POOL CERTIFICATIONS: �'�'— •y�; The pool supervisor must be certitied 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. � �. 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 a years'records. You must provide new copies and maintain a tile at your place of business. � 1. 2. ; 3. 4. �._...._�.___... ._ FOOD PROTECTION MANAGERS-CERTIFICATIONS: �.,a'a�:�� All food service establishments are required to have at least one full-time employee who is certified as a Food �T� ��._ 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. � `'�"; -e You must provide new copies and maintain a file at your establishment. � �. .�A�c� ' /��l,U��'�� Y 2. m a/.� y m c1�N� �. `� � -,. PERSON IN CHARGE: �.. � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. l.-�i��S�T me.JnJ��y 2. �a�� K 12��p ALLERGEN CERTIFICATIONS: 3, �I1 OLLy �►') (f��/7 � 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 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. �. ��y m��'l'�y 2. �oN� � f�c�� HEIMLICH CERTIFICATIONS: 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 anti-choking 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 tile at your place of business. �.�a�/� � (zvsso 2. �r►o�(.y ��f�i�y 3. 4. RESTAURANT SEATING: TOTAL# lD 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 SWIMMING POOL$110ea. _LODGE $55 TRAILER PARK $105 WHIRLPOOL $]l0ea. FOOD SERVICE: LICENSE REQUIRED FEE P T LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 ��SI 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 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ �v��Q� ****'pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �30��_1�4—632�-a� ADMINISTRATION i , � 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 CERT.OF INSURANCE ATTACHED � OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio 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 ar 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 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 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 Department to schedule the inspection three(3) jdays 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 closing. FOOD SERVICE i � 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 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. 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 COOHING: 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 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,201'7. 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 �E�IT LAN. DATE: �� "� SIGNATURE: PRINT NAME&TITLE: �G/'�ilt K SS� Rev.10/l2/17 . r ,�,�;�,,,�„� �-"�"14CI�.G!'�� +ll�+t�'�n.� �(�.�� 55 {Policy Provisions: WC o0 00 4ta C} /7 46 cB INFQRMATIt3N PAGE �c WORKERS COMRENSATtON AND EMPI.t)YERS UABI�ITY P41.ICY (N$URER: TW�K CITY FIRT INSURANCE CUMPANIY ONE HARTFQRD PLAZA, HARTFORD, CONNECTICUT 06I55 NCCi Comparty Number: �.4��4 THE Compar�y Code: � HAR T FOR D - s�tr� . UkR9' RENEWAI ' POLICY NUMBER: d8„WEC CB9655 � 20 � Previaus Policy Numbs�: Q8 WEC CB9655 .. . .. .., HOUS ING CflDE: SB .�—_��. t, i�t�n,e�sc��i�l��r�-;pds�eaq�;��. �rtc z--.asA �r��c>w�s �us,_ (No.,S#reet,Town...S�te..�iP Cod$) . , . - 53 U �LD 'T4WNHOUSF� RdAB F��N��: SOT3TH YARMOUTH, MA 02664 :, • ,::, ,. . . „ . State Identification Number(s): Th@ N8t11@d(f1�U1'@d�,5: CORPQRATION BtiSf1188S Of NBrttEld ItlSili'e�l: RESTAURANT Other aera�lcplaces not shawn abovs: i''�' sotrx�t Y.�tr�ouTx ru, oz6s4 2. Policy Period: From o2/a311� T,� 02/23/18 12:Q1 a.m.,Standard time at the insured's mailir�g address. Pr�uCfsrs Ndrrte: ��u INStTRANCE AGENCY ING PO BQX 355 _ W<,YAFtMOUTH. :MA 02673. ': Producer`s Code: 084404 , Issuing Office: . T�E HARTFORD 301 WOODS PARK DR2VE � CLIN'I'ON NY 13323 (8U0) 962-6170 Total EsEimated Mnus!Premiurtt: S2,116 . Depo�it Premium: `_�► Policy Minimum Premium: 52�.� t�x � i � . �y ��.._........ �; � Audit Pefiod: �� Installment 7ern�: The policy'is not bincting ur►less cuuntersigned by otN aut�orized represer�tative. Gouniersigned by �`�av,� L'��'.u„�.j o 1I o�/�� Autharized Representative Date Farm WC 00 00 01 A (1) printed in U.S.A. Page 1 (Continusd on�ext page) Process Date: 01l0�/1� PolicyExpkatfon Date: 02/231za '�-�-�, .�"""'e � I HOSP1TALiTY'" 1p6 Southviffe Road-Southbarough, MA 01�72 M UTUAL��S;iNpr� rs��:;s�che R»K ouc 3t r,�;.�a��t„ Toil Free{877)366-1140-FAX:{5Q8)836-494G� ; j L(QUC�R L! BILITY DEC�ARATIC3NS ; � � TYPE; 4ccurrence Policy Number. 0�3834Q'!LL THIS DECU4RATIONS PAGE AND NDORSEMEPITS, IF ANY, ARE PART QF Y4UR P k.ICY. NAAAE t3F INSURED(maiting�dress} PRODUCER: M.A.A.M., Inc. D/B/A 'Patriot tJnclenrvriters,lnc. Longfeilow's Pub i63 Raute 130 ( 53Q Old'Fownhouse Road Bordentown. NJ 085�5 South Yarmou#h, MA 02644 � ti PPOdUt��'S�OdB NO.: 1811 . � ; PC?L1CY PERtOD: From: t�t1912U16 To: t0119120i7 Time: i2:Q0 AM � stanaard Time at the address�tt�e I�ured iaes aa afetec!trenePn. 1 LUC NQ. INSURED PREMISES 001 530 C�d 7cn�mFwuse Road.Soulh Ya ,Bam�t$b{e County MA,02654 � LiMITS OF INSURANCE � { Limi� $2�,000 Per Person � � Limit: $500,0t)0 Per Occ�urrence � Limit: $500,000 qggregate i L.ic�uor Sales: $425,000 � D SCRIPTI4N OF BUSINESS FORM Q�BUStNESS; Carporation ; , ; ; BUSCNESS�ESCRIPT�ON: Restaurant i � ; � a i Pc�licy Number. GLASSIFiCATIt}N AND PREMIUM oa�ss�aoi� �pC CODE NO. COVERAGE � � NQ. LiMlT OF LIABiLITY PREMIUM ( 001 Mod-Restaurants-f'squor saies 4Q96 more of toiai�a{es 35 � 7otal Pr�temiutrt: $5,797 i � ' � �� .` � �� '� { � i p � y� 4 te} �0�#��Q��QV t j ra� 1 �!J i I it&U��C� ! I ,