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Home My WebLink AboutApplication and WC vg.FR vf::r O TOWN OF YARMOUTH BOARD OF HEALTH - , '-9V C t 7018 APPLICATION FOR LICENSE/PE T -2/49,1-1,„„#,,, EALTH • PT. _ * Please complete form and attach all necessary ocnen y Dec•' •, • , :. NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15th. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: 5Ltfr,54_00 smotc. I TAX ID: LOCATION ADDRESS: S a 5 10 " o r l TEL.#: q-_ 3(t8-3a MAILING ADDRESS: ' I G b) 0 S 0.m►.04'1 01 A 0olLPCP y E-MAIL ADDRESS: S.p6511(-An CI) c 6\ , Yin OWNER NAME: P/1 c 0 A Siloor\\re , - L e CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: Oa CO Q k 6,o\t t o til. 1 TEL.#: S 3 c c 5-51 MAILING ADDRESS: gr,me a9 cclno'r--- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated -Pao-1-Operator 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. Raber'I--� r ( 2.,JG sl cpt i y' c t3. Pfrbel r i c, tk fpr1 4. t 6 tin, cc 1^ I^ i 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. 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. 2. 3. 4. 0644 1- — 15-4(2-1 -CM RESTAURANT SEATING: TOTAL# Q HQ-( -L(?Z-OLt OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P ,4 I'�, ,G B&B $55 _CABIN $55 1 MOTEL $110 �'7 INN $55 CAMP $55 _k_SWIMMING POOL$110ea. �7S' , 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 = $ 2.20.-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 C PENSATION 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 prio 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 RE UIRE A SITE PLAN. DATE: /1 -J '/cr SIGNATURE: PRINT NAME&TITLE:, .-/-7,1/6 )( (Oenf Rev. 10/23/18 SKP IM-1 Q' OP ID:DP CERTIFICATEOF #+SURA: osrsesinisnyirryNCE RIS 7x14312017 ``, TE RISSUED AS A LICES MATTER C.1F INFORMATION `AND CONFERS NO RIGHTS UPON THE CERTIFI ATE.. ® T QTflI ICA DOES NOT ARFFIRfIVEI,Y OR NEGATIVELY AMEND.; -t ® OR ALTER THE COVERAGE AFFORDED BY THE PQ T i"i'IFICATE 0E-i'= NSURANCE DOES NOT CONSTITUTE A"CONTRACT BE 1WEEN.TNE ISSUING INSIJRER(S). AUTHORIZED ATNF OR UCER,AND THE CERTIFICATE R�'i $ENT n HQ40�, IMPORTANT of t o . - cste bolder is an ADDITIONAL INSURED,Die Pol cy(ia s)must a embed If SUBROGATION M WANED`,subject to the`ter ms and "„ of he policy:-cel ;liolicies.may A endorsement. A statemen`on this certlftcate does not confer rigtEs to the e°holderim° suofsuch s) � B t DtiP=Mil Insurance Agy,Inc. l mnce. ,Inc,• .�" CT 119.8 1 is Tail _ , ,_ v .$08G8811- T3s{_ Gordon ..,,... 1018 aoune s:" .� S LLC; PI 1 Techk noiojjfr Ins Co.=9IAM'FRUST ` ?31 LLC dtrpt wsul�t s T - S moo: . . Obi Wig: x CERTIFICATE t�U REVISION NUMBER YIS TQ 11 THAT THE- ®,, SOF ' , NC'IIIVIT}IST' , c �-- - LISTED SELOW RAYL BF_E ISSUED TO THE INSURED4=0DOCUMENT WITH R_.� +„ � ' 4 70 • MAY {�Jt 1AAY PEi THE INS. -..,baa: • s+® , • AFF'•, CMD ST THE POLICIES DE�FFiSED HEREHV IS SUBJECT �7tl:I' AN . • OF SUCH-MES LIMITS` MAY HAVE BEEN R CED BY PAIDCL AIMS. =OFUdI EileumEpp COIF Cl/LGENERM.UA8I TY �Rg a a m $ 1� Li OCCUR INEOEXPtarqmp!s�+ii x:. . PERSRS0NN:$AD INJURY. S` .-z, - RALAf3 GATE`." $ GENT TELIMI APPLESP5k PRODUCTS f PACO S_ �POLIC f 1 LOC'. S ri ANY .. .-..._Aisulo B�Q0k1f1NJURly(PKpMgpn Y el.�ar(P.r H�AH'rOS • ;Ai1r08 1PER� � m .._.. ___:..0P.,-,qui:,' EACH OcCURR f,. �..-.� CIJUIrtS MACE AtitDiEGATE $ Y Bs s,n a :N?A TWC:3626360 0513W2018 05 12019 ;E:L'EACH ACCIDENT $ 100.000x M EL:DISEASE.EA DY€E t 100,E 'zOF OPERAflON$bNow E.L z` L .-.. T10Md!1 pp EBt(MIacR JNMRD 191 A Ionil I apace is p) Y CEI TIt=1 1 0 flON sur.,. ,. ,. ANy OF THE AgovE Toatn of Yarmouth ,_pollen i�lrt6rc>� - S:YarinRoo'u"t ,MA ` 'Gordon'` . I . .. 1 10-A•• , CORPORATION' Ap rtgle le+ed. • , 1 ) The AGORO name and are gistered marks of ACORD