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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH t. ►' APPLICATION FOR LICENSE/PERMIT -2015 NOV e 5 [U 14 * Please complete form and attach all necessary documents by Dec' be 014. Failure to do so will result in the return of your application I war ' - ' PT. ESTABLISHMENT NAME:FOOu,crv► 131 TAX ID: LOCATION ADDRESS: I3 t rl'tPit y 6-j P)64t c( TEL.#:jdg-6,Q4-733/ MAILING ADDRESS: 7:0, c5zNt 3100 5:#;t/wt° " 14-/A' 0026 Co 4 E-MAIL ADDRESS: S XC i 0 601 . C6 „.. OWNER NAME: Ili yV)tV'h r S''' Z LG CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: (Yl I C,1�-C 1 KO fit TEL.#:_5 -q0/-77.1 y MAILING ADDRESS: {�'G , 661 11 CT SlCa rY1u fli it a,--, 6'5' . POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, 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 years' records. 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. fh chq-e\ kra 2. PERSON IN CHARGE: Each food establishment� must have at least one Person In Charge (PIC)on site during hours of operation. 1. alf t& >,a, e Varnr 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. N l C.hr,'6 KAO-C 2. 3. 4. RESTAURANT SEATING: TOTAL# 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 P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 1 0-100 SEATS $125 / -62-I _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 ‘ COMMON VIC. $604f-/S-0 Iii —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: $15 AMOUNT DUE = e$ I BSck. -6(0 PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** t ' 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 V 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 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. 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, 2014. 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: y--/y SIGNATUREC21 PRINT NAME & TITLE: f'CrllCf/)1 oicva n ir4i /710"247-et" Rev. 11/03/14 : AC R SKP1 M-1 OP ID:AL �- CERTIFICATE OF LIABILITY INSURANCE I DATE(M«IDNYYYY) 1/07/2014 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 policyfies)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 DGP-Mites insurance Agency2%74fncACT DGP-Mites Insurance Agy,Inc. 3 School Street P.O.Box 1018 Eat:508-8244961 Taunton,MA 02780-0957 I Fax m.Not 508-880-2734 Gordon G.Mack MAIM. ASS: INSURERS)AFFORDING COVERAGE NAIL# INSURED SKP1 M,LLC INSURER A:Technology Ins.Co.(AMTRUST) dba Skippy's Pier INSURER B Sandra Di Giovanni NNsulvatec: P.O.Box 370 INSURER D: S Yarmouth,MA 02664 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. USSLTR TYPE OF INSURANCE M SUjT (MOUC EFF POLICY EXP MN3R IMODPOLICY NUMBER Yt rRMIpD/yYYYt LENTS GENERAL LUQ 1TY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ I CLAIMS-MADE I I OCCUR PR RENTED goccurrence) $ MED EXP(Any we pin) _ $ —I PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEM.AGGREGATE APPLIES PER PRODUCTS--COMP/OP AGG $POLICY r ' FrT I LOC AUTOMOBILE LIABILITY $ ANY AUTO a )) $ SINGLE (E — AUTOS ED AUTEOS ED BODILY BODILY INJURY(Perperson) $ HIRED AUTOS S INJURY(Per accident) S RTY DAMAGE S (PER ACCIDENT) -- (ROLA URB _ OCCUR $ EXCESS LIAR CLAIMS-MADEEACH OCCURRENCE S DED 1 I RETENTION$ AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY A ANY 1"/N IWCSTATU-I IOTH. TWC3410199 ITORY LIMITSI 1 ER �y�s tory In NH) Rn teER EXCLUDED? n N IA 05/30/2014 05/3012015 E G EACH ACCIDENT S 100,000 (MandeOFFICEpTION OF OPERATIONS petow E L DISEASE-EA ma'i $ 100,000 EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES(Attach ACORD 191,Additional Remailos Schedule,Imore space is ) , • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ., q ACORD 25 2010105 01988-2010 ACORD CORPORATION. All rights reserved. ( ) The ACORD name and logo are registered marks of ACORD