The URL can be used to link to this page

Home My WebLink AboutApplication and WC GIEC ENIED _ TOWN OF YARMOUTH BOARD OF HEALTH DEC 6 2010 �- APPLICATION FOR LICENSE/PERMIT -2019 * Please complete form and attach all necessary documents by Decant ; ;_;',ILLTN-DEPT NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORM "- • Failure to do so will result in the return of your application packet. 0143 L -., 'Gs, N1. ESTABLISHMENT NAME: ,(;;v si �� TAX ID: " LOCATION ADDRESS: .3 caro <</ 4``��/? Oc 673 TEL.#: ;�O8'arc,/`/96 MAILING ADDRESS: �0 a niMo•'7 4J('Alf/9Pe / ts7vfN /��,1 O,Q///7— E-MAIL E-MAIL ADDRESS: OWNER NAME: -`141-5/i}Aga /thf-i T 9�• CORPORATION NAME (IFAP LICABLE . MANAGER'S NAME: Mfr ,-,;"70-- 4'v TEL.#:30 FS'g1'/`/9',5 -" MAILING ADDRESS: 5'?4` es„ ., .77- (2 l"/Z eIA/,sem• /,2ya'2' .0a6 '2 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operate (s) and attach2De4' a copy of the certification to this form. r 1. . C4,�1 c /�'v 2. Pool operators m�ust 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 yearsrecords. You must provide new copies and maintain a file at our place of business. 1. D/1 De Z9e-1 cR, 2. ,..d,t eii 4 U 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 defi d in the State Sanitary Code for Food Se yic stablishments, 105 CMR 590.000. Please attach copies of certifi i tion to this application. The Health D •artm le t will not use past years'records. You must provide new copie and maintain a file at your est ishment. o EWLED 1. 2. DEC 0 6 2018 PERSON IN CHARGE: H Efi T DEPT Each food establishment must have at le. one ' -rson In Charge (PIC)on site during hours of opera ion. I 1. Alibi, 2. ALLERGEN CERTIFICATIONS: All food service establishments .,e required to have at least one full-ti --employee who has Allergen certification, as defined in the State Sani . v, Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to : application. The Health Department will not use past years' records. You must provide new copies an► 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. 2. 3. 4. RESTAURANT SEATING: TOTAL# 50A-5P-6-2-308—Oq OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 INN $55 —C$ 55 MOTEL $110 $55 SWIMMING POOL$110ea 5 _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 —COMMON VIC. $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. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 110 *****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 1 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: V 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 m 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 RE A SITE PLAN. DATE: /,), SIGNATURE: PRINT NAME&TITLE: Seevrf Yex- 4,2 - Aro.. Rev.10/23/18 CHARWHI-03 JLOOMIS '4i�,-4:›REY CERTIFICATE OF LIABILITY INSURANCE °"'�`"""°°"""' 11/14/2018 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 POUCIES 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(les)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 an INs certificate does not confer rights to the certificate holder In Neu of such mss). PRODUCER MILACT Jane K Loomis,CISR,CIC The UC� vlln Insurance Group =ILE„p:(781)235-3100 241 I rA e:( N, 781)235-1022 Wellesley,MA 02482 ss;AlLoom)s®chinetnnce cotta IMAMS AFFORDING COVERAGE NAC! INSURER A:Rockhill Insurance Company 28053 INSURED INSURER B:Hartford Fire Insurance Company 19682 Charles White Management Company INSURER C: 330 Commonwealth Avenue INSURER D Boston,MA 02115 INSURER E: 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 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. LIR TYPE OF INSURANCE MD WED WED POLICY NUMBER U YVYY) osimsivrvm UMITS A X COMMERCIAL GENERAL mown EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OMR GENLO18940-01 011082018 01/0812019EMI ' ,*- RENTS rroe) 100,000 ood -' To(Eaocwrre $ MED EXP(My one person) $ 5' - PERSONAL&ADV INJURY $ 1,000,000 GEML AGGREGATE UNIT.APPUES PER GENERAL AGGREGATE $ 2,000,000 p POLICY JECf LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE UABR)TY (COMBINED Ea )INGLE LIMIT $ANY AUTO BODILY INJURY(Per person) $ OIANEAUTOS SCHEDULED BODILY INJURY(Per aotldent) $ _ MaONLY NAUpTµOQSy AUTOS ONLY _AUTOS ONLY (Per acolaeru) 'E _s $ UMBRELLA UAB OCCUR EACH OCCURRENCE 3 EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS B WORKERS LO 'u A*aON X STARTUTE ER OBWBCLDdZ53 0?1D?/2018 021D?/Z019 EL EACH ACCIDENT $ ANDPROPRIETOR/PARTNER/EXECUTIVEEMngt UDED? N N/A r '000 y�y�, EL DISEASE-EA EMPLOYEE$ `x,000 descrthe under DESCRIPTION OPERATIONS below EL DISEASE-POLICY UNIT S500 '000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES worm TOT,AddMmd Remarks Schedule,mey Imease ed Name apace is required) RE: 345 Camp Street,West Yarmouth,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Town Of Yarmouth,Board of HealthTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN I1H 1146 Route ACCORDANCE MTHE POLICY PROVISION& South Yarmouth,MA 02864 AUTHORIZED REPRESENTATIVE ACORD 25(2018103) ®1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • PDF created with pdfFactory trial version www.pdffactorv.com