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Home My WebLink AboutApplication and WCi ` ` RECE �' � TOWN OF YARMOUTH BOARD OF HEALTH � APPLICATION FOR LICE�� ,,, �E� �� zO�� * Please complete form and attach all n�c�s'�4 u�i t ece be EPT. Failure to do so will result in the-� f'�u"r-a� {` " ion p � � . � ESTABLISHMENT NAME: D TA : ' LOCATION ADDRESS: �t�0 V R7'�*`"�,4� TEL.#: �`D E�-��T�;33d•� MAILING ADDRESS: S AMr�' � E-MAIL ADDRESS: S ��1C OV O PA��t�- � C,C�M C AS 7°'. N�T � OWNER NAME: �A t/L CO#��1 N�'�{'0 , CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: O�l� T'�L+'+�.M �5�N TEL.#: Q' �� ' � MAILING ADDRESS:_ 2. t 0. 1� f L�. � Q * W+��`, 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), 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. �. rv I A 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. �O�tATi��tN Cl,�RI�l� 2: �_��t" 1f1�{�A'A1rld�!'� PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. , I. ��L�R t�'f R,��N . z. � ALLERGEN CERTIFICATIONS: All food service esta.blishments 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. �. �A�-�'�.,�i t�'i .4'SON` 2. N�►fi/�L„i� M,t,S'a�t HEIMLICH CERTfiFICATIONS: ' 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. �. A�'!^ t,�� f��tq�orv z. W� R12�'�+fi M�S 3. 1f 'i►Qr IC 4. r 414�H RESTAURANT SEATING: TOTAL# - --- _^ . --- _— — _ ----- - -F OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 �N $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��100 SEA SS $200 ��'�� Cp�pN�� $60 �f O _WHOLE3ALE $80 i RETAIL SERVICE: —1tESID.KITCHEN $80 �` LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# f <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25' F _<25,OOOsq.ft. $150 =FROZENDESSERT $40 =TOBACCO $110 ' � NAME CHANGE: $�s �vtoulvT DUE _ $ /B5.OO '. *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ao�F"�5'��o�"r�3 I I I , , ; ADMIlvISTRATION j I Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ` e 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 1NSURANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED � f Town of Yarmouth ta��es 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 sha11 be i 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 f 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. i POOLS POOL OPENING:�11 swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health D�partment prior to opening. Contact the Health Departrnent 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 f 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 outdoar in ground swimming pool must be drained or covered within seven(7)days of ' elosing. ' _ _ FOOD SERVICE , i SEASONAL FOOD SERVICE OPENING: � All food service establishments must be inspected by the Health Departrnent prior to opening. Please contact the � Health Deparhnent to schedule the inspection three (3)days prior to opening. M � - � CATERING POLICY: ; Anyone who eaters within the Town of Yarmouth mus� notify the Yarmouth Health Department 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.yarmouth.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 I submitted to the Health Department. Failure to do so will result in the suspension or revocahon of your Frozen Dessert Permit until the above terms have been met. I OUTSIDE CAFES: � Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. ` OUTDOOR COOKING: ��I 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 RETURN I 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 REQUIRE A SITE PLAN. DATE: SIGNATURE: � PRINT NAME&TITLE: ; i � Rev.10/12/17 I 1 ' � �� SEAFSAM-02 KSEARS '`�coRo° CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYI� `•� 1/17/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVEIY 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 hofder is an ADDITIONAL INSI{RED,the policy(iss)must have ADD{TIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the ternu and conditions of the policy,certain policies may require an endo►sement A statement on this certificate dces not cwifer rights to the certificate holder in lieu of such endorsement(s). � PRODUCER C ACT R ers 8 Gray Insurance Agency,lnc. v�owE F,ox a�Rte�sa �,No.�r. �a�,��:(8T7)816-2�ss South Dennis,MA 02660 E'�"� .mail�rogersgray.com � INSU S AFFORDING COVERAGE NAIC# u�su�a:Arbella Protection tnsurance Com an Inc. 41360 � INSURED iNsur�x s:MA Retail Merchants WC Grou Inc. ! Seafood Sam's of S.Yarmouth,inc. n+sur�c: 'i dba Seafood Sam's 1006 Rte 28 INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER P: 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 TFiE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION 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 TypE pp�N8URANCE �� POLICY NUMBER � �CT EFF POLICY E7� V� A X COMMERCUIL GENERAL W181LITV 'I,OOO,OOO EACH OCCURRENCE $ CWMSMHDE �OCCUR $��Orj47H2 O�O/YO'IG O$/YO/YO17 DAMAGETORENTED 700��0� PR MI S Ea occurren $ � MED EXP M one n $ 5,�� veRsowu�s aov iruua�r g 1,000,000 GEN'L AGGREGATE IJMIT APPLIES PER: GENERAL AGGREGATE $ a,OOO,OOO X POLICY❑�� LOC PRODUCTS-COMP/0P AGG $ 2'��'�� o.n-�ER: NONOWNED $ 1,000,000 A��VAB�� COM&NED SINGLE LIMIT Ea acci eM $ ANY AUTO BODILV INJURY Per rson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODIIY INJURY Per accident $ AU�0.S ONLY q�7N�S p�NLY PROPER,�TY DAMAGE $ � Per UMBRELLA LL46 OCCUR EACH OCGURRENCE $ EXCESS LIAB CLAIAIS-MADE AGGREGATE $ DED RETENTION 5 B WORKERS COMPENSA710N AND EMPLOYERS'LIA&IJTY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTNE Y/N 014005032775116 01/01/2017 ��/0�/2��$ EL.EACHACCIDENT $ 500'�� Q_Fe C�t��MNH�EXCLUDED? � N/A �M EL DISFASE-EA EMPLO g �O,OOO If yes.describe urMer r�0��0 DESCRIPTION OF OPERATIONS beiow EL.DISEASE-POLICY LIMIT E A Liquor Liability 8500054782 03/20/2016 03/20l2077 Each Occurrence 1,000,000 A Liquor Liability 850005I782 03/20/2016 03/20/2017 Policy Aggregate 2,0OO,OQO DESCRIPT'ION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 707,Addkional Remarks Schedule,may be aUached if mors space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth TNE EXPIRATION DATE 7HEREOF, NOTICE YYILL BE DELNERED IN ACCORDANCE 1NRH THE POLICY PROVISIONS. 1146 Main St South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ,--' �/f� �I� ACORD 25(2016l03) 01988-2015 ACORQ CORPOR/j,�16N. AII rights reserved. The ACORD name and logo are registered marks of ACORD