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Home My WebLink AboutApplication and WC Rr: GMED 4.) TOWN OF YARMOUTH BOA' 1 a F,HEALTH .- NOV 3 7(118 APPLICATION FOR LICENSE ` IT_- 0 7,5 7 .: HEALTH DEPT. * Please complete form and attach all necessary.::. s i ents by barber 13, 2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 1P. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 4 0 j V frc-K =S/ <E51< TAX ID: ') LOCATION ADDRESS: Imo-` (QA TEL.#: S'o 3 -.55.a.a_ MAILING ADDRESS:'arnnb WA.ft- E-MAIL ADDRESS: q Oa co a 1Q h ice cow-ICi 1071-- OWNER OWNER NAME: 4 le-la + 5)uj( l..>...)c1.4-&h &1->.P CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: A`1 - U.Da4 a ale TEL.#:414 -qq tt-) �q 3 MAILING ADDRESS: Sc -t-'Pe POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator quired by State law. Please list the designated Pool Operator(s)and attach a copy of the certification s form. 1. 2. Pool operators must list a minis. •1 of two employees currently certified in standard First Aid and Community Cardiopulmonary Resusci . 'on (CPR), having one certified employee on premises at all times. Please list the employees below and . ch copies of their certifications to this form. The Health Department will not use past yearsrecords. : 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. DaLa h6L 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 2. 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. 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. 1.A a c, 2. 3. 4. RESTAURANT SEATING: TOTAL# Pjo�j -- -03t9-os 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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 � — CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 I COMMON VIC. $60 —WHOLESALE 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 = $ 185.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 ATTACHE!' 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 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 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 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 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 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 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 CAFÉS: 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 product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license, and the tobacco license cap is reduced. 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, 2018. 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: t 1i.{II D L SIGNATURE: (4 PRINT NAME&TITLE: A icfG ��`-1'/ Gh�� f kIJ & • Rev.10/23/18 TE(Y11/DWYYW} AccoRD CERTIFICATE OF LIABILITY INSURANCE DA11107/2018 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(fes)must 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME PHONE FAX Automatic Data Processing Insurance Agency,Inc. Na 6dk (A/C,No):1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC o INSURER A: Empioyere Pretarredinmance Company 10346 MIMED • RIMER B INAHO JAPANESE RESTAURANT INSURER C: 157 RTE 6A Yannouthport,MA 02675 SOURER D INSURER E: ISURERF: COVERAGES CERTIFICATE NUMBER: 1020552 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSO VIND, POLICY NUMBER ( M ) UNITS COMMERCIAL GENERAL LIABSJTY EACH OCCURRENCE $ DAMAGE 10 RENTED CLAIMS-MADE OCCUR PREMISES(Ea eminence) $ MED EXP(Any one person) _ $ _ PERSONAL&ADV INJURY _S GENT.AGGREGATE LMR APPUES PER: GENERAL AGGREGATE $ iPOLICY I Jac LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COIN SINGLE LIMP/ $ ANY AUTO BODILY INJURY(Per person) $ ALLOWED SCHEDULED - BODILY INJURY(Per aoddenQAUTOS AUTOS $ A HIRED AUTOS AUT ONMED PROPERTYDAMAGE $ OS UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE - AGGREGATE $ DED RETENTION$ I • $ WORKERS COMPENSATION �( I AND EMPLOYERS LIABILITY AME 6R ANY PROPRIETORIPARTNERIFxEcuTivE YIN ,... EL EACH ACCIDENT $ 1,000,000 A oFFICERR i7(CUX)£D't I Y I N r a N EIG2485�601 05/0?JZ018 05102/2018 (Mandatory in NH) - EL DISEASE-EA EMPLOYEE 5 1,000,000 O�s�ResasreOlder DFa9CRIPTTON OF OPERATIONS below - EL DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Ad NIonai Remarks Schedule,may be attached If mom space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Ma-28 South Yarmouth,MA 02864 AunHORIZBE REPRESENTATIVE AO 1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD