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Home My WebLink AboutApplication and WC ....1______ RECE VI o---- --- TOWN OF YARMOUTH BOARD OF HEALTH MAY, 2 8 2019 u., ' APPLICATION FOR LICENSEIPERMIIT-2019 *Pleasecomplete form and attach all necessary documents by 8 IS 8. HEALTH DEPT. AALL BUSINEYSESWITH IJOIQRMEWS MUST RETURN? BYE IbAfBER15° Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME:,$.rcr.(Stwtlt 3).44404.3 Ili 440.4% TAX ID. ?' LOCATION ADDRESS: 2 20 e&a N. S4 yaaactr tbo Ihr4TEL q• SyE-419 '/'di MAILING ADDRESS:,24 Nsp S.x Jt. Q.ro•+iactI st f it 62-9 03 E-MAIL ADDRESS�•,j'per rea,.dl..s4l.f3j p.1.4••••OWNER NAME: .10 o.tivokFii arfw.4 CORPORATION NAME(IF APPLICABLE): 6.11, Awl 1441-40- Co•ct.rs•,aa+St hop • MANAGER'S NAME C mrii ph.I to tee, 1 ELI: MAILING ADDRESS: 'r ' a;' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by Shite Iaw.Please list the designated Pool Operators)and attach a copy of the certification to this form. 1. 2. u� Pool operators must list a minimum of two employees currently certified in standard First Aid and Community o Cardiopulmonary Resuscitation(CYR),having one certified employee onat all times. Please list the , employees below and attach copies of their certifications to thisform.The Department will not use past years records. You must provide new copies and maintain a file at your place of business. I. 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 wo not use pastyears'records. You must provide new copies and=ahrtal'a file at your establishment 1. ti•.. 244i Midi n tJ j,1 2. 643 (beeper& • PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. L t..t stet“: a tJ.d 2. C4.n1 tie(.ki--{ . ) K +�r^ow+ ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergencertifcation, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. You must prove new copies and maintain a file at your establishment 1. prose rt f�R.c�rwl•vk 2. • HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heinilich • Maneuver on the premises at all times. Please list your-,, ees trained in anti-choking procedures below and • attach copies of employee certifications to this form. The 'ri9,• 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 P 0 a —`0,_'�6 C�CE OFFICE USE ONLY wncmvG: �! LICENSE REQUIRED PEE PERMIT It IICEME REQUIRED FEE PERMIT it IICEMIE REQUIRED FEE PERMIT It B&B S55 CABIN S55 MOTEL 5110 —INN S55 CAMP S55 —SWIMMINGPOOL SI10ea. _LODGE $55 MAHERPARK 5105 _WHIRLPOOL SlMOsa. FOOD SERVICE: 0100 F PERMITS LIC IRED FEE5 PERMITS LIC NON-PRREO[JItED PERMtTS 330 >100 SEATS $200 COMMON VIC. S60WH OL SALE 910 ZZIRRETASKtVICE: KITCHEN SIO IICENSEgRKREEII. EED FEE PERMIT# uce REEQ. IRED 5 PERMITS ENSERi00 lig PERMITS a5,M0sq.S. $<50 150 - l� TBURT SAO —IUBACCO $110 NAME CHANGE: Sts AMOUNT DUE = S 19-5.00 . PLEASE TURN OVERAM)COMPLETEOTIHERSI)EOFFORM"••• 1 eye ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is nowregnired 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 X 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: YES _ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT the ANSIN and shortCterm OCCUPANCY: or Pum of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the tem have have and able to pane,ordinarily and customarily associated with motel and hotel use_Transient occupantsdemonstrate that they maintain a principal place of residence daewhen t Transientoccupancy vice n lyrally nuf erx o contimonuh s occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days y 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 MAIL.c.640 or 830 CMR 640,as amended,shall generally be considered Transient POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season be inspected by the Health Department prior to opening. Contact the Health Deptto schedule the inspection must_(3)days prior to opening,PLEAS NOTE:People are NOT allowed to sit in>be pool area until the pod has been inspected and POOL WATER TESTING: The water mist be tested for piendomonas,fatal coliform and standard plate carat 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 dosing FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department to schedule the inspection three(3)days prior to opening Department prior b opening- Please contact the Health CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Healtheoby filing required Temporary Food Service Application form 72 hours pier to the catered event. These form bet 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 CAFES: Outside cafes(i.e.,outdoor seating with waitedwaiUrss 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. I ii NOTICE:Permits run annually from January 1 to December 31.ITIS YOURRESPO1NSIBILTTy 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 MAYA SITE P DATE: 'q1..1414 SIGNATURE: L 1 PRINT NAME&TITLE: �Owcj wpLA.c.,,�-y�_�j'"t'""um ! el.A. +a,N Rev soezr�ha V� ki l'.J V � ,w,_/ r . h I A o�RD� CERTIFICATE OF LIAB11.1T1f INSURANCE DATE 111111/00MYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF OFORIMATION 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 MlSURER(S).AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the serMleate holder Is an ADDITIONAL INSURED,the Polley(les)must have ADDITIONAL INSURED provisions or be endorsed. It SUBROGATION IS WAIVED.subPet to the terms and°ondi ions of the polio,(Nrtein policies may require an endorsement A statement on this eertMeate does not center rights to the osrtlloate holder In Neu of such endorsement(s). PRooIIcaR wwrAcT SCHNEIDER MordInsuranceAgent IMO PAS imo x(401) i (401)296-5721 PO Eat433 North 10rlgstaen,RI( 5 )433 SchmiderewicNDrdinsurenosoorn IMILMENN AFFORDING COWMEN MSCI INSURER A: HARTFORD CASUALTY MS CO 29424 , Name FIRE AND WATER CONCESSIONS,INC. Vis: 785 Middebridge Rd W41�ELD,RI0 79 MOMS C: NOM D: MEURER is SOURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS 10 CERTIFY MAT THE POLICIES OF INSUMNCE USTED BELOW HAVE BEEN ISSUED TO THE INStXED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING NW REQUIREMENT.TEM OR CCADITTON OF ANY CONTRACT OR OTTER DOCU TENT WITH RESPECT 10 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES WATTS SWAIN MAY HAVE BEEN BLEED BY PAID CLAMS .NNI 1 TYPE OF INSURANCE AIM SUER Y EFF t ,POLICY OP` UNITS COMMERCIAL GMERALMINUTE EACMOCCt $ DAMAGE TO Remo I CLMdSMADE 0 OOCIR PREVIEWED eocurreneel S MED DP(Mryens mien) $ PERSONAL&INV INULY $ HL AGGREGATELeer APPLES PER ,GENERAL AGGREGATE ,S -_ POLICY❑: UDC P4100(/TB-00 PASO i S ,AUTOMOINLEUAINftY r/r9 CONINED SMOTELINT S ANY AUTO SOOLYINJURY(Perpenon) $ OWED NJ0$SCHEDULED 800LYMNRY(Per=Mere) $ NAOS AUTOS ONLY OS ONLY NONOYMED PROPERTY tl° 0E $ AUTO $ wean JAIJAa OCCUR EACH OC RCE S 10055$WM CLANSMADE AGGREGATE $ DED RETENTION $ A WO COMP i 02 VI EC AD7ZKK 0601/7019 05.01/2020V 1 I 1ER AND EMPLOYER,UABEJTY Y/N N/A E.L +A $ 1.000,000 8CUAEDRillendigery In MN E10 -EAEMPLOYEE a 1,000,000 II describe tnder1,000,000 - OFO 2IONSbelow EL DISEASE-POLICY'JAR $ D5SCRPTWN OF OPERATORS/LOCATIONS/VEHICLES()CORD 151,AMltlen.l Remarks SeMdde,Mob*aldeMd Ir more epees Y reputed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIED POLIES BE CANCELLI BEFORE THE EXPRATHON DATE THEREOF, NOTICE Wil BE DELIVERED N TOWN OF YARMOUTH ACCOIOJWCEWITH THE POLICY PROVISIONS. AR M ROUTE SOUTHAMORE=cAMORE= mnuE e. YARMOUTH, A0261J6644 ,� � �y E t 1 ®1989-2015 ACORD CORPORATION. Al rights reserved ACORD 25(2016103) The)CORD name and logo are registered marks of ACORD