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Home My WebLink AboutApplication and WC t \ � ' �-,�___ 3( . , �� TOWN OF YARMOUTH BOARD OF HEALTH '�PPLICATION FOR LICENS�YP� "F � , � £ (��V ;% r ��jJ � * �� ; rlease complct�form and attach all necessary`documents b�Dec ber 1 S 2017. Failure to do so will result in the ret�m of your appl�c��'`pa�ke��._��eti __1 __� ESTABLISHMENT NAME. T ' LOCATION ADDRESS: G Z g TEL.#: ' MAILING ADDRESS: �. S- rn do�- G� E-MAIL ADDRESS: S- G �I CJ .�i6 ►"'� OWNER NAME: -e L CORPORATION NAME (IF APPLIC �E): MANAGER'S NAME: � l G�CJ�1°� G Yl'-� TEL.#: ' G ' a� `� MAILING ADDRESS:___ ____.�,t .h'�-r a `� C�lo%'V-f 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), 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 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'reeords. You must provide new copies and maintain a file at your establishment. i. ��L��I �G +^-�- 2: �. �,� gr� d��'� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. ��"�Q�� (�5 G n '� 2. � ►<,, gr' f� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined�i�the State Sanitary Code for Food Service Esta.blishments, 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. n'1;'tc�,G�-��,�''�- 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-chaking 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. �. ��h��e1 k� ��- 2. 3. 4. RESTAURANT SEATiNG: TOTAL# � ' OFFICE USE ONLY LaDGING: 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 P�� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 � CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 1 COMMON VIC. $60 � WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE�tEQUIRED FEE PERMIT# f <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 f —<25,000 sq.ft. $150 —FROZEN DESSERT $40 TOBACCO $ll0 i NAME CHANGE: $is AMOUNT DUE _ $ I S S�OO I i *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ; �o�F--Ly-6316-0�{ � , ' ''�� :: � 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 prior 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 or 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 sha11 generally refer to continuous occupancy of not more than thirty(30)da.ys,ar�d� ` an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or � k 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 OPEl�iING:t�ll swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Conta.ct the Health Department to schedule the inspecHon 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. { i . 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. i i FOOD SERVICE � � I SEASONAL FOOD SERVICE OPElvING: � 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 Deparirnent by filing the required Temporary Food Service Application form 72 hours prio� 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. OUTSIHE 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 procluct 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 RETtJRN ` THE COIV�PLETED 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 E PLAN. � ; DATE: �d �r SIGNATURE: �� .�,..�� PRINT NAME&TITLE: d�:..�,� ; � � Rev.10/12/17 � F t � , � ��"^'� SKP1M-9 OP iD:AL ACORO DA��qwownm� �.,._.,_ • CERTIFICATE OF LfABiLITY INSURANCE 10/03/2017 THIS CERTlFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTtFICATE DOES NOT AFFIRMATNELY OR NEGATIVEI.Y AMEND, EXl'END OR ALTER THE COVERAGE AFFORDED BY THE POLiCIES BELOW. THIS CERTlFICATE OF INSURANCE DOES NOT CONSTiTUTE A CONTRACT BETWEEN TFtE tSSU1NG INSURER{S), AtlTHORIZEQ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certi8cate holder is an ADDITIONAL INSURED,the policy�iss)must be endorsed. !t SUBROGATION iS WAIVED,subjec!to the tenns and conditioru of the policy,ce�tain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in{ieu of such endo►secr� s. �oucEa r�: DGF-Miies Insurance A ,Inc. DGP-Miles Insurance Agency,inc �E FNc 3 School Street P.O.Box 1018 •508-824-8961 � N,;5Q8-88Q-2734 Taurtton,MA 02T80-0957 E Aoo�ss: Gordon G.Asack '� s ��E �* ��A:Technol Ins.Co. AMTRUST n�so�o SKP1 M,LLC dba Skippy's Pier 1 �urt�R e: 731 Main Street,LLC dba Tavem 731,277 S.Shore Or. ��R�� LLC dba Surf 8 Sand M�ei p�guRER p; Sandra Di Giovanni P.O.Box 370 ��E: S Ydnnouth MA 02664 �wsur�R F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTEQ BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD lNDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OP ANY CONTRACT OR OTHER DQCUMENT VIATH RESPECT TO WFtICH THI3 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURRNCE AFFORDED BY THE POLICIES OESCRIBEO HEREIN iS SUBJECT TO ALL THE TERMS, EXCWSIONS AND CQNDITIONS OF SUCH POLICIES.LIAAITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAlMS. � Tr�e oF a�suw►►�ce voucr wurieEtt a� � �E��B�m EACH OCCt#tRENCE S CONN�RCfAL GENERAL LIABILITY �� r PREMISES Es ocarrence S CLANdS-MADE �OCCtiR b�0 EXP(My or�p�spn} E PERSONAL&ADV NVJl1RY S GENERALAGGREGATE S GEML AfaQREGATE LNYNT APPLIES PER: PRODUCTS-COMPlOP AGG S POLICY PRO• LOC a ,*�p�y�p��Ty p�tED MIGLE L9N Es accident S ANY AUTO BOOlLY INJtIRY(Per petsm) S ALL BWNED SCHEDULED BOUItY INJURY{Pa accideau) S AUTOS AUTOS HIREDAUTOS �p�� p�,q��pE� S S UMBRELLA UAB �CUR fRCH OCCIH2RENCE S EXCESS ltAB ClAU41S�MVIDE AGGREGATE '� S — DED RETENT1�15 S LA�RKERS C�APENSATWN VYC STATU- OTH- AND EMPIOYERS'LIABdITY � A ANY PROPRiETORJP/UiFt�WEXECUTNE Y 1 N C�26�8 0513Ul2017 0513W2018 E.L.EACH ACCIDENT S ��r O�FFICEq1AAEMBERpCCLUDEp� � N!A (Ma�WtDory M NN) E.L DISEASE-EA EAAPIOYE S ')OO, Nye&desaibe� DESCRIPTION OF OPERATIONS ltelow E.l.DISEASE-POLICY lqi!(T i �Or DESCRlPTIQM�OPERATIONS/LOCATbN3/YEfqCLES(Attach ACORD 101.A�itlonal Romnks Scf�le,H mon spaat is roqulnd) � t f f 5 4 ' CERTIFiCATE HOLDER CANCELLATiON � SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BHFORE � ( Town of Yarmouth 7t� �w►noH nn� ni�oF, Nonce wn�� se oEuv�eo m ; 1146 ROttt@ 28 ACCORDANCE W(TH THE POLICY PROVISIONS. � S.Yarmouth,MA nun+owzEc aEvnesEHramre � C1a+v:....�.�� i U �1988-2010 ACORD CORPORATION. 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