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Home My WebLink AboutApplication and WC , . �.�'�f'1��.d�..�Z��.� ( � TOWN OF YARMOUTH BOARD OF HEALT�,�5.e � ��T � d�d�� APPLICATION FOR LICENS�E�tI�ITT -�p1'$ 'a, ` f ,� - . .. �� , � r-n-�- 't � * Please complete form and attach all necessary documents�'by�en�.�,`;�D�-2`_..==-'�.� Failure to do so will result in the return of your application packet ESTABLISHMENT NAME: `� C�i'��'►�Ct`/�, „s�t�t t� 'vf .:-�z�< TAX ID: . LOCATION ADDRESS: J.3�� 2 ,,r�r/� �,r.m��/� .-�'�i�� EL.#:(S�U�)�yy- 71�c,� � MAILING ADDRESS: �Ct .l��'.�'��rY�L�u�.,.�l��s�.�-��✓ti� ��.�' �� '� E-MAIL ADDRESS: �'C'r,�-�»�� l/�,�i G�f.J Cu clir��r;/, fo�� OWNERNAME: JG'�"o.� ��'��c�l.- � , �J•µ�`S/C>U ��,'�;Cf✓G' CORPORATION NAME (IF APPLICABLE): ,�a� / �,e'� MANAGER'S NAME: /�� e?c°t;�Chc�� TEL.#: S�&' ly 1 -C'�.y'� MAILING ADDRESS: �rG�dlr�.� . 'rrr.�° ��' 1.��/.f��.�c�ul/� �'� CJ 1�7.� 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. l. � 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. 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 file at your establishment. 1. /�'��/� ��r''��c`l �c��' 2: �FJC�v.�G� !/Ci r�+/!��'Ci PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. `�' � ��'` '�.��/ �r ��r �>. i�� f �-� , /�t[:+�9 �_' � 2.-- �i :S/ ��'f/ c.��1� � .�r`✓Z 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. !��,S�C<v ��+,` 1/,�✓G' 2. /1`'�G�c�sGo G C°.'L�Crrl UC.'.!"j. 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. 1. �� — � �+ ,� /��S��'t /�' ��,`✓�'rr� 2. ��'�'aG�4/G'! l/�t,LaCii��IJ�I 3. 4. RESTAURANT SEATING: TOTAL # -�� ____ � _ _ ---_ --__ _ _ _ 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 $110ea. FOOD SERVICE: � LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 l -0`�{.O CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 / COMMON VIC. $60 �C�J� =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 NAME CHANGE: $15 AMOUNT DUE _ $ 1�J. G�J *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r�j��F—`�—6�JCJ� �� 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 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 t� 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 shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not mare than ninety(90)days within any six(6)month period. Use of a guest ur�it 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) 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 pseudornonas,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. FOOI3 SE�tti ICE 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 Boazd of Health. OUTDOOR COOKING: 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 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, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY�Tr�IE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE FL�� DATE: ,�i%�`.�� /� SIGNATURE: 4��R °,k';� ,�G't� C-/l liL!/ ��c,�'�J � PRINT NAME & TITLE: /U'C�� ' �; Rev. lo/12/17 � �G/,`.� S��i,�, ��,�� ,r,��i�G.' � �� , L� �Y7 �,r" � � � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ` 1 Congress Street, Suite I00 Boston, MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name:_ Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBar/Eating Establishment 2.L 1 I am a sole proprietor or partnership and have no �. � Office and/or Sales(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We axe a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy inforr�zation. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to a i,SGG.iru andiur one-year imprisonment,as weII as civii penalties iri the form of a�TUF'WUtZK OI�ER and a tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. - Signature: Date� Phone#: Official use o,�ly. Do not write in this area,to be completed by city�r town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Cierk 4. Licensing Boa:d 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia A�R� T��s cERriF�-�--��i�ATE�S issuEp AS C�RTIFICqTE OF l.IqgILITY IfJSU CERTIFIC �� "-'-'-- RANCE ATE��5 NOT AFFIRMATIVETLY R OF INFORMATION �A7E(MM/DD/yyyy) BELOW. OR NEG ONLY AND CONFERS NO RIGH7S UPON THE CERTIFIC THIS CERTIFICqTE OF INSURqN��pQ�S REPRESENTATIVE p ATIVELY AMEND �9�13/2017 R PRODUCEk_qNp NOT CONSTITUT �XTEND OR ALTER THE CpVE ATE HO�DE �MPORTANT: If the certificate holder is anrqpp ERTIFICq7'E �A CONT �AGE AFFO R•TNIS If SUBROG -'-��----------_ HQLDER. RACT BETW RDED By THE P ATION IS EEN TFiE ISSUING INSURER(S), AUTHOR�ZED this certificate does notconf�er ri hts tq t�e Ce �rIONAL INSURED, the ,subject to the terms and conditions of the Po�icy(ies)must have ADDITIONAL INSURED PRODUCER ��nson Youn ��f�cate holder in lieu of suphlendorse '_ g& Downs Ins Y�certain policies ma p�OVjs�ons or be endorsed. SoSA koute 2g ment(s), y�eqUire an endorsement. A statement on P U Box ?58 coNracr �:________ Kathy Jones_ H�M/ICfI POf( WHONE � -- �,�u�_---508)432-1256 �•MAIL FAX -----. MA 02646-0158 -�Fs.s___KathyJones�a byandd.com •�508)430-1532 - _ _ INSURED -�-------_. ----- � . .__.._----------------------- �---------_INSURERlS AFFORDWG COVERAGE E7&I Corp __ ------_.____ iNsuHeR n_Norfolk&Dedham Yarmouth House of Pizza -- --,__Mutual "--- - IHSURER 6� ��-- NA1C# 40 Bamboard Lane ----- 23965 INSURER C_ ---- '- West Yarmouth - --- MA 02673- �NSURER D: -'�_ COVERqGES _ia_3_URER E: �_ — THIs IS TO CERTIFY TH CERTIFICATE NU N ReR F -"— INDIL'ATtD � AT �NE POLICIF.S OF INsu MBER: � HC,7VV��H{gTqNDING ANY RE RAN�F.LISTE��E��W HAV�N�SSU�p TO TfiE INSURED NAhAEp qgOV CFRTIFICATE MAY BE IS,��-� � �UIREMENi iE REVISION — RM oR CONp�7ION oF qNY NUMBER: iNSR - ------2 MAY PF RTAIN.IJMITS SHOWN M AFFORDED gy(THE pULIC EST ESCRIBEp�NT 7 _ noo�s�eR HE E FOR THE POLICy pERIOD _�USIO_NS_ANp CONDIIIqNS��F SUCH AY HAVE BEEN hL0 �TH RESPECT TO WH�CH TYPE pF INSURANCF I T UCED 8Y PAID C HEREIN IS SUBJECT TO ALL THE TERM �__j �MERCIAL GENERqL LIABILITY i � ' � IC'If S � co ' ��'- -N IICY N MBER ��POLIC �IMS. Y EFF EXP —___ S, _ _i CLqIM � I I � � POUCY�T--- S-M.4DE � � '---J OCCUR � � LIMITS r � � �i I EqCH OCCURRENCE � �� ---. -- �� - D�MAGE TO RENTED '_ $ '�''-MLAC(RGGATE LIMI1�APp ICS f[:�j�-----r i� i MED EXP $ ---- �� ' - �PR� � f" � one erson $ . .NO�I(`y�•- --: dEC 1 )' i�� PERSONA�g ADV -_ii1_1Ef2 - i � � -'---�_. INJURY 5 � � GENERq�qGGREGA7E _._'-_------� . I � TOM081LE LIABII_ITY �-------^-'- � � $ _._I �--_.__..- �PROD - ucrs• ANY AUTO -' ---- ----- �--- COMP/OP AGG $ I j OWNcL �— , i- ----�---�__------- �OM6INED $ ., l--J AI�COS ON( ' ,�I A`�TODU�ED �� I � SINGLE LIMIT Y '— j � $-'—^-__ -�AUTOS ONLY � �UN��ED f� I � � � BODILY INJURY(Per � a AUT�S ONLY ! � � person) g '� � BODILY "'-�-------L I �� '� - i INJURY(pe�ac�ident 'UMBRELLq(,�qg T� "- -..�_I I . PROP��- � $ ? � I TY DAMqGE � EXCESS f��qg - I Oi;CUR : �'-'�-'----._._��_ � $ � � �- I .' --- - <.�-�IMS-MAp� �� $ JG� . kCIENIION � � A WURKE �-- �ACH OCCURRENCE -"' RS COMPkN RiNER/F . � '--�N ,� WE 1------.__- -.'--�--------�---�-� .__._��__ � ----__ 'AND EMPLOyCRS IIABII.I�IY AGGRE !A�'}�p�npR I E7� /1540A � i-----cnr�_ s �R�� E��'��v� �' �09/15/2017 �OI-FIC,ER/MEM6ER EXC,,UpEp� � --�' 1(Mandatory ln NH) ��N/q! 09/15/2��8 EP R $ I I/yes,descnbe��nder � � 07H- ip_, i RIPT" �pERATI � -1 N F �yS�� W � I � E.L.EACHACCI�EN7 g 100,000 iI -"'-----. I I E.L pISEASE-EqEMPLOYEE $ 100,000 �'__'. '----r--��___'-------�_ E.l.DISEASE� -- ----- I � POLICY LIMIT $ 500,000 DESCRIpTION UF OPERAT70N5/LOCqTIONS i VEHICLES ' I Pizza Shop af 1311 Route 28 South Yarmouth, T �A��R��01 Additional Re �'-'�- MA 02664. marks Schedule,may be attached if —I- � more space is required) :ERTIF�_��qJE HOLDER _-`_ ~�`"a------- CANCELLATION Tawn of Yarmouth AI 059964 Lir�nsing�ePt SHOULp qNy UF THE ABOVE DESCRIBED POLICIES 9E CANCELLEp BEpORE 1146 Rte 28 A CORDAN E W�H D E pOL CY PR01/�SNpNS�CE W�LL BE DELIVERED IfV South Yarmouth MA �2�j64- AUTHORlZEp REPRESENTATNE ------�.,__.__. �RD 25(2016/U3) '� �� --- ' ' �-f�d---- The ACQRU ��ame anri In�� ,,� ��_;,_. _ �1988-2015 ACORD C �/ ORPORATION. A��i9hts reservecl,