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Home My WebLink AboutApplication and WC r I RVal Vi iii TOWN OF YARMOUTH BOARD OF HEALTH .: 1' APPLICATION FOR LICENSE/P+ ;, T--,4 Ol5 , ' e ?n i 8 * Please complete form and attach all necess tai ocuments .Y..-t'..iV4,/ - _ /_ NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST�TU' F '►� aiiii1++11.15; yc h Failure to do so will result in the return of your app�lication packe . ESTABLISHMENT NAME: )K`PQy 15 PIC f TAX ID: LOCATION ADDRESS: !' krcak n i LA n TEL.#: a8.3q815 . MAILING ADDRESS: Po w r 310 S.1al'wta n^A- OZc / E-MAIL ADDRESS: S 3hQ)44Vl 4 G I . (_ c1^" OWNER NAME: j �t 1•(B N r_pdMYYC t-cmAt. LL C. CORPORATION NAME (IF APPLICABLE): p`M i L LC MANAGER'S NAME: at bnti`rCC Dk G'csv 0..•- TEL.#: 3 y,K51 MAILING ADDRESS: 3Com r 4 S of bv-A- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Fool @ I- •_ • : `-a-copyof the certification to thisform`__ 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 yearsrecords. 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. 5coelr � t � toy 4to2. AQron Se(thcr PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. Stt rtotrgD t tov4,wt4 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. Soda 01Gtcsv4,nz 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. SQA rt" PSG `dlr[a.nh t 2. 3. 4, RESTAURANT SEATING: TOTAL# 252 ej Q i} F— `C f—0317—0S-- 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# 0-100 SEATS $125 _ CONTINENTAL $35 NON-PROFIT $30 I >100 SEATS $200 4049-115 I COMMON VIC. $60 4/9--0 7 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 = $ 2.G0-00 *****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 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 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: f(/Z1''( SIGNATURE: PRINT NAME&TITLE S¢/14/475V-A-4(14142 01 Rev. 10/23/18 -- CERTIFICATE OF LIABILITY IhNRANCE Dd1T1�031201 YYi 14/0017 THISCERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Q f'AN D CONFERE'NO>RIG1HTS UPON THE CERTIFICATE HOLDER.THIS ATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND.,EXTEND Oft ALTER THE CO GE AFFORDED.BYTEE POLICIES . THIS CERTIFICATE OF INSURANCE , $), ��`k� , DOES NOT; CONSTITUTE A CONTRACT=� j a= s EEN TIfE, UiNG ursulms( AUTHo OR PRUCE1;AND THE CERTIFICATE IMPORTANT cif the c`ate holdet`ls an ADDITIONAL INSURED,thepollcy(lss)must be.endorsed If$ =®_ ®{ ,IS In, sObioot to !ha and conditions of the policy,certain policies may require an`en�sement. A statement certificate does not ids to filo _ hoIdr Insthu of such rd(s; ur, �, l'e h rae�ce�, tic k „ P=Miles I ura a Myr Inc: Ta •''''',-.11)%1:1.' ,t , utrc rim SQ&880-2T3�1 t3ool `;. Nan• +rte 81031m,LL6A Technology Ins (AMTRUS'T) Pier I :NISUIIER8: Tay vn ,277$ Shot*Dr. Vi : L,LC`dba Sats$$isml tdOtel San lnsDIalovannl IINNIo. - , 70~ Vie`: j tI2 64 NN}t R F.• .:. ® „„,57-,,`‘,—...„,,,,,,..:,,,,v4:4, .- CERTIFICATEsNUMBERt $„ .. , , ,�q R N 3 4,14-1-0-J! -'IIFY ThAT:THE P"9:140, ES OF IN ANCE LISTED BEl O1N HAVE BEEN ISSUED TO THE INSURED-NAMED A F SPO'' �' . NO Z' ANY RE htUIREMENT,TERM OR CONDITION of ANY CONTRACT OR OTHER DOG ENTlieu. CEXq�TEMAY BE ?®v*,R4MAY PERTAIN,THE j ' ", m T DESCRIBED HEREIN IS. TO-THIS IOt4 REDUCED BY PAID CLAIMS •q� OF SACH fE$,LL : , � EIAAY FI�1 �l,ll1:TME 3'1?RMS LTR ,'44:-*: TYP0OF0 NC ;1. 0l1! `. UM cm/Same!.sotSsivol. ANM.I y, 8 I Ct/sesssessE[ OCCUR PAEoExP(PAyone�qor4 $ . PERSONAL&ADV INJURY $ GENERAL AEGATE $ _Gena TEI I$T,AREL$1$PEl PRQQUCTS P.OU n LOC $ surf ,� r;. �; ANYAUT-0 ,,,,._ ,.~ LED 000 YINJ JRYEP posse) $ _ 01IN.1F'NIJUR 8 I!EPu aoeidoTIq $ 'HTE-0 AUT°S �=;AUTOS (PIM9=�D'UAciit I. B" S ' t EACH uiliguRRENCE I CIAIPAINEADEGATE S WC ATtt- Q , « ti....tia ANY l4Al illy NM TWC3626368 05130/201$ ,0513018°19 5 EL E�ACHACCIDENT S 100,000 -' r E.L ONIEASE-EAEIYN'I,OYEE S I � ''`',. , SOFOPERATi ,below ELDISEASE_-POLICY1 ASt .S.= D 11ON;OFOPERATIDNSSLOCAATIONSIVINNDY. '(A IiAC011D161.Adire Rq s MinaewoeN dn01 • CERTIFICATE�QtAER`. : . CANC TION :$MOULD ANY OF THE ABOVE Flee E CP#1• Lti PRE Town of Y THE EXPIRATION DATE THEREOF, NOTICE WN.L GE ,OELly�•D,,it. SITHOO h ACCORDANCE WITH THE POLICY PROVISIONS. ,v. - 1146 RoUte 2$ • AUTHORISEDsl-YarmOuth,MA aErranva. Gordon G.Mace T ti-01-1; AN rights reserved. >D18>�-301t1�lC.oR1� s � -i- a - - 0 A12010/05) The ACORD name and logo are reDISTOTsd marks of ACORD