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Home My WebLink AboutApplication and WCi � $__ �tE-�Pf�.s � , _ � ` TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/��I�I , '1� `� <r � ' �� `� �'�'��]' _ . , � ''�''� * Please complete form and attach all necessary,doc ,> 'b� �ce�'e ' r 1 :ZA�-7. - __ Failure to do so will result in the refur�:nf y ' �pl�e�ati+�ri ac ----��-- -- -�-- ESTABLISHIVIENT NAME: � S �r r T ID• LOCATION ADDRESS: t rl �1� '{�lY� LC n-� TEL.#: - " � MAILING ADDRESS: �� IQ G 3�1(� S- 0��(r��'1 ►'�"lA �-�e�o - E-MAIL ADDRESS: S uS �1✓► w G a . ( ��"► lA � I�t n OWNER NAME:�� L g � � t..a+��, �, L � CORPORATION NAME F APPLICABLE : � ) MANAGER' vt t� i �,bvG v�n � S NAME: S� d .P TEL.�: MAILINCr ADDRESS: Pb 1� 3�(Cj S��Gtrm� �� 6�CoCp �-1 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 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), 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. L 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 estabGshment. ' �. Ph� I�p I-I-�I�, 2: ��a►� ►^��'�� PERSON IN CHARGE: Each food esta.blishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. Ph�1� t�,h ►� z�nd�� (� 6 � dv�� - 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 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.�j,t�� n �ch � 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-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 file at your place of business. �. ��ndr� D � G, ��, � ► 2. 3. 4. RESTAURANT SEATING: TOTAL# �5�' ' OFFICE USE O�TLY LODGING: LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' BBcB $55 CABIN $55 MOTEL $110 IlVN $55 CAMP $55 SWIMMING POOL$i l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE• LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 =>100 SEATS $200 ( • / COMMON VIC. $60 �� —WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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: $i s AMOUNT DUE _ $ �.(0 0�O O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �jo t�-�-l�-63('l-0� ! � � ADMINISTRATION � . F 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 CO PENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ' CERT. OF 1NSURANCE ATTACHED OR . WORKER'S COMP. AFFIDAVIT S GNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prio o 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 OPENING:All swimm,ing,wading and whirlpools which have been closed for the season must be inspected by the Health D�partment prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLE�SE 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 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 requ�red Temporary Food Service Application form 72 hours priox to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.Yarmouth.ma.us under Health Department, Downloadable Forms. __ _ � FROZEl�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 Boazd of Health. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. ' NO�ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETiJRN 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 UT A SITE PLAN. DATE: /��'��`� SIGNATURE: � � / i PRINT NAME& TITLE: �Y �l l �!�'�l��t� h Rev.10/12/17 ' � � - 1 �"r"'� SKP1M-1 OP ID:AL '`�'r'�R� CERTIFICATE 4F LIABIL.ITY INSURANGE DA�tM��m ,o,o�zo,� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATiON ONLY AND CONFERS PIO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTtFICATE DOES NOT AFFIRMATNELY OR NEGATNEIY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POL{GIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CER'flFICATE HOLDER. IMPORTANT: Ff the certi8cate hoider is an AODtTIONAL INSURED,the po0cy{ies)must be endorsed. ff SUBROGATION IS WAIVED,subject to the tertns and conditions of the policy,certain policies may require an endorsement A statemertt on this certificate does not confer rights to the certificate holder in lieu of such endorsems s. 3 PRQDUCER � DGP-Miles Insurance A ,Inc. � DGP-Miies Insurance Agency,lnc � .5p8-824-8961 F"� � 3 School Street P.O.Box 1018 u ac :508-88�-2734 Taunton,MA 02780-0957 E�s, � Gwdon G.Asack �SU S AFFORWNG COVERAGE !WC M u,surea�n:Technot Ins.Co. AMTRUST uasur�o SKP1 M,LLC dba Skippy's Pier 1 ��R�: 731 Main Street,LLC dba Tavem 731,277 S.Shore Dr. �+��R�� LLC dba Surf 8 Sand Motet GISURER D: Sa�dra Di Gtovanni P.O.Box 370 ��E: S Yarmouth MA 0266A INSURER F: COYERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CER7IFY THAT THE POLIClES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PdUCY PERIOD INDICATED. NOTIMTHSTANOING ANY REQUlREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH RESPECT TO VHHlCH TFIIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLlCIES DESCRISED NEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MHY HAVE BEEN REUUCED BY PAtD ClAiMS. LTR TYPE OF INSURANCE POLICY NUMBER MfDD/YYYY LbA1T5 GENERAL UABlLRY EACH OCCURRENCE S COI�RCWI GENERAL LIABtLITV PREMISES Ea oxurerxe S CLAAdS�MADE �OCCUR MED EkP(MY ane P�son) S MA ' PERSONAL 8 ADY MIJURY E GENERALAGf�REGATE S GENL Af,GREGJI7E LR�AIT APPLIES PER PRODUCTS-COMP/QP AGG S ��, PRO• L� S AUTOM0811E WBN.ITY Ea a WeMS LMA1 S ANY AUTO BODILY fNJURY(Per person) S AIJTO�S�E� AUTODStN_ED BODILY INJURY(P�axideM) 5 HIRED AUTOS �pg�� PER ACCIDENT� S E UMBRELLA UAB �C� EACH OCGURRENCE S EXCES3 Wl8 CLNMS�lAOE AGGREGATE ' E DED RETEMTION 3 y vwowcer�caxr�snnoH v�s�rwru. oni- AND EIMPLOYERS LIABLLiTY A ANY PROpRiETORIPARTNER/EXECUTIVE Y r N C36Z6368 05/34/2Q17 05I30/2018 E.L.EACH ACCIDENT $ �� OFFICEWMEMBER EXCLI�ED? � N J A I(�yes be�Nir der E.L OtSEASE-EA Et�I.OYE S �OO, OESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY IMtlT S 500* i i DESCR�PTION OF OPERAitONS/LOCAT10N3!VENIC�ES(Attach ACORD 101.Ad�tioml Remarks SeMd�d�,q mon spae�b iequiwd) I j! I � � � � CERTIFICATE HO�DER CANCELtATiON � SHOULD ANY OF THE ABOVE DESCRIBED POIICIES BE CANCEILED BEFORE j Town of Yarmoutfi T� �P��T�N DATE THEREOF, NOTICE WIL! BE DELIVERED IN j 1146 Route 28 ACCOROANCE W[TH THE POLICY PROVISIONS. � S.Yarmouth,MA A��Eo��rarn� � C'a+�.»�.�$ v \ � � �1988-2010 ACQRD CORPORATION. All rights reaerved. � ACORD Z5{Z010/OS) The ACORD name and logo are►egisbered marks of ACORD � 4