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Home My WebLink AboutApplication and WC� �� ,.� �� TOWN I�F YARMOUTH BOARD OF HEALTH " � � APPLI�ATION FOR LICENS °(.�, T' -��i �� i � 2��j e'"` * Ple e c m lete � � ::�' ' �. , � �<.. as o p form and attach all necess dq��i��'i��S ,; be 1 S 2017. � � � � Failure to alo so will result in the ret'�" of�t,�p��'ica ion ��-��-� ��'�' ESTABLISHMENT NAME: -C Sw ...tr � TAX ID: � � LOCATIONADDRESS:��.,p( S'r�'n�� (�.'�-� . S� �/�AS?wc��c.�'EL.#: S('>Q� �� -,�[�S`�t� MAILING ADDRESS: > > " � E-MAIL ADDRESS: Y"�� S�t,�.7t-<< �.A� W��C• C�^� OWNER NAME: V�tf2 t1C\�, 5w�-c,c- CORPORATION NAME (IF APPLIC�BLE): T-��-��Q�Q j��,. MANAGER'S NAME: C?,�C•r� ��0. v� �,f�uw��1[�(„�au TEL.#: MAILING ADDRESS: �1 l.Q l 5�u,r� •t�v• S• �I�tl w�v'��. 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 o employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CP , having one certified employee on premises at all times. Please list the ; employees below and attach copi of�heir certifications to this form. The Health Department will not usepast years' records. You must p ide n�w copies and maintain a �le at your place of business. i � L 2. 3. 4: � ; FOOD PROTECTION MANAGERS - CERTIFICATIONS: j 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 tlhis application. The Health Department will not use past years'records. � You must provide new copies and maintain a file at your establishment. ' 1. �j�,'�2�C'2�\ J l,.t.9�G✓�s---- 2.��J! ��"'�[..`C 1f�-L-- I� . ERSON IN CHARGE: C , Each food establishmen ust have at least one Person In Charge (PIC on site during hours of operation. 1. 1�/'��RN,� ��w'"'_" 2. V� ALLERGEN CERTIFICATIONS: All food service establishments are requ�ired to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code far 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. l. l 2. 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 file at your place of business. �. c��ss4 �.. a�� Q�,� �� 3. 4. RESTAURANT SEATING: TOTAL# `'�b OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $I10 INN $55 GAMP $55 SWIMMING POOL$1 l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1 l0ea. FOOD SERVICE: �ICENSE REQUIRED FEE PE_ RM�# 'LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-]00 SEATS $125 l$�� CONTINENTAL $35 NON-PROF[T $30 _>100 SEATS $200 �COMMON V1C. $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. $I50 _FROZEN DESSERT $40 TOBACCO $I 10 NAME CHANGE: $15 " AMOUNT DUE _ $ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �j0+��- L� -D32.�-b� 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 COMPL�TED AND SI�GNED, OR. " � ' CERT. OF INSURANCE ATTACHEDi . OR , : , WORKER'S COMP. AFFIDAVIT,SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior,to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY��F PAID: � � , ' YES NO MOTELS AND OTHER LODGING ESTAB�,ISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel�r Hotel use,Transient occup�ncy 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 occupaincy 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 subje�t 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) days prior to opening. PLEASE NOTE: People are NOT allowed to sif 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 CLO�AT�:Every ot.tdoo�in ground swimrrring pooi must be drarined or covered�ithin seven�7)day�a�— - closing. „ . 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 required Temporary Food Service Application form 72 hours prior to �he catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us underHealthDepartment, 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/waitres's 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�ood service establishment is prohibited. NOTICE: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, MOTEZ, OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED B�Y THE BOARD OF HEALTH PRIOR ' TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: �,[�� a.0 " �� SIGNATURE:� v � r PRINT NAME & TITLE: �R�` S t�t' � Rev. 10/12/17 1 � -� � � DATE(MMIDDIYYYY) ,�►`oRD CERTIFICATE OF LIABILITY INSURANCE 10/30/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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 have ADDITIONAL INSURED provisions or 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 certifcate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER C�0 EACT K�S KO reski � Mark Sylvia lnsurance Agency,LLC PHONE . 508 957-2125 aAiXc No: 508 957-2781 404 Main SVeet E�,i� ADDRES •mafK marks Iviainsurance.com C2f1i2NIIIB,MA 02632 INSURER S AFFORDING COVERAGE NAIC# iNsuReR n:Farm Family Casualry Insurance . INSURED iNsua�Rs:Hospitality Mutual insurance The Grump Incorporated Dba Sweet Tomatoes Pizza INSURER C: 170 Hollingsworth Road Osterviile,MA 02655-2153 iNsurteR o: INSURER E: i � 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 INDfCATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITIQN 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 ADOL SUBR pOLICY NUMBER MMIDD YYYY MMIDDIYYYY LIMITS LTR . A X COMMERCIALGENERALLIABILITY ZOO1X'I553 11/30l2016 11/30/2017 EqCHOCCURRENCE $ 1,000,000 DAMAGETO RENTED 100,000 CLAIMS-MADE a OCCUR PREMISES Ea occurr ce $ i MED EXP Any one person) $ 5,�00 { PERSONAL&ADVINJURY $ 'I,OOO,OOO � GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 2,000,000 � X POIICY❑�E� � LOC � PRODUCTS-COMP/OP AGG $ Z,OOO,OOO $ OTHER: I - AUTOMOBILE LIABWTY E�a aBatleD SINGLE LIMIT $ . i ANYAUTO � BODILYINJURY(Perperson) $ � OWNED SCHEDULED � BODILY INJURY(Per accident)�$ _ AUTOS ONLY AUTOS HIRED NON-0WNED PROPERN DAMAGE $ AUTOS ONLY AUTOS ONLY Per ccid n $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCE55 LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ � /� WORKERS COMPENSATION 2001 W8131 11/30/2016 1�/30/2�17 STATUTE ERH � AND EMPLOYERS'LIABILITY Y 1 N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? �Y N�p` 'I,OOO,ODO (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Liquor Liability 00105720LL 11/30/2016 11/30/2018 Per person-$1,000,000 Peroccurance-$1,000,0 0 Aggregate-$2,000,000 . DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may 6e attached'rf more space is required) Piaa restaurant Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed 4o have altered,waived or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ToWn of YemlOuth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 - -�_ South Yarmouth,MA 02664 . AUTHORIZED REPRESENTATIVE � � ' OCT 3 0 2017 • O 1988-2015 ACORD RPORATION. All rights re erved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD �..3��,1"(� DE�FT•