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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALT �� .. �� APPLICATION FOR LICEI�E 2�n hOV O72013 � * Please complete form and attach all neF e�¢ ctame ts 1� ecember 73 2013. Failure to do so will result in the i�iurn�ye�ar��p�ic io �I DEPT. ESTABLISHMENT NAME: ° TAX ID• LOCATION ADDRESS: e o � �0 2 EL.#: S aD MAILING ADDRESS: E-MAIL ADDRESS: �P{-v��a+t�Z C/75' � A D . Go rvr • OWNER NAME: CORPORATION NAME (IF APPLICABLE): os ov� y-�i o ' � c ��'-`+'v o MANAGER'S NAME: TEL.#: 8 0 MaiLnvG.�D�ss: � V 2013 POOL CERTIFICATIONS: HEALTH DEPT. The pool supervisor must be certifie as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of certification to this form. 1. Pool operators must lis minimum of two employees ently certified in basic water s , standard First Aid and Community Cardiop onary Resuscitation(CPR) ving one certified employee on p ises at all times. Please list the employees bel and attach copies of their c ifications to this form. The Hea epartment will not use past years' records ou must provide new co ' s and maintain a file at your p e 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. le �` S �eYnuvr c�c ? 2._, Qt�1� el✓l>1�iU� � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i.� (.>iS T2vv�u�e/P'7 2. �Llil�e� / e��%Jafa4'D� ALLERGEN CERTIFICATIONS: All food service establishments aze 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. � (> i .S �2.Yv! a r� G�C 7 2. / ' A!�1 u$� � e vvr c�a a{e 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-chokuig 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. i. i�,'s F��,a� �� z. a�r�� au�_� 3. a a e/ rCGt�' 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 $55 INN $55 CAMP $55 SWIMMINGPOOL $SOea. LODGE $55 7RAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ! 0-IOOSEATS $85 :�'I�I-vct CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $160 �COMMON VIC. $60 �r�c�t- _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. $225 VENDING-FOOD $25 � —<25,000 sq.ft. $80 _ —FROZEN DESSERT $40 _TOBACCO $95 NAMECHANGE: $15 AMOUNTDUE _ $ I`}�J,OO •**••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 tases 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 lunited to the temporary and short term occupancy, ordinazily 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 thirry(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. _ _ _ __ _ - - F067SSEI�-VI�;E _ __ _- -- _ _ __ - SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Deparhnent 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 Deparhnent, or from the Town's website at www.varmouth.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 ofyour Frozen Dessert Pertnit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoar cooking,prepazation, 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 RESPONSIBILIT'I'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. 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 PL DATE:_ /� - v�- /3 SIGNATURE: PRINT NAME&TITLE: y n a Y)0,� Rev. ]0/08/]3 . ,.� � � on-r�ta�renroorvvrr7 I ��'�� CERTIFICATE OF LIABILITY INSURANGE � io/3ol2ois ; 3 �� hll$ GERTIFICATE IS ISSUED AS A MA'ITER qF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER7IFICATE HOLDER. TH�S CEftTiFiCATE DOES NOT AFFIftMA71VEi.Y OR NEC�AFNElY APAEMD, EXSEND OR ALTER THE C6VERAGE AFFQRDED 8Y THE POLIGES �:� BELpW. TN�S CERTIFICATE OF INSURANCE DOES NOT CONSTITU'fE Fl CONTIiACT BETWEEN THE �SSUING IN5URER(S), AUTHORIZED ��.. REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. ! IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,Ne poiicy(fes)musi be erMoreerl. Ifi SUBROGATION IS WAIVED,subject to � ttre terms and condi4ions of the polVcy,csrtai�policies may require an entlorsement A sta2ement on thls cerUficate does not confer rights te the � ' ceKificate hotder in iieu of sucl�entlorsement(s�. � PROOUCER w,RnE: Sames E Sullivan � Suliivan Insurance Agency PH�Na�„ 9788519600 !�rvor9788514$48 ! 885 Main Street Ao�"��.tewksburyinsurance@msn�com I Tewksbury, � �1.876 I INSURER(9) AFFORMNG COVFRAGE I ��A I � � �wSURER a:MA Retail Aierehants WC Group Inc. ( INSUREO Four Seasons Trattaria lnc iNsuaeae: + {� INSURER C' I f � 10?7 RTS 28 �r+su�zEa o. `. South Yarmouth, MA 02654 �iNsuaERE � 1 IN5URER F' ' COVERAGES CERTIFICATE NUMBER: REVISI6N NUMBER: ' TIiIS IS TO GERTI�Y'fNAT THE FOLlCtES OF tNSURAidCE USTED BElOW tiAVE BEEt3 lSSUED T4 1NE fN5URED WafAE6 ABOVE FOR THE POIICY PERIOD j �'�. INDIGATEb. NO'TWITHSTANDING ANY RH(�UIREMENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER DQCUMENT WI7H RESPECT TO WHICH THIu ! i GERTIFIGATE MAY BE ISSUED OR MRY PERTAIN, TME tNSURANCE AFP4R4ED 81` 7HE POLtC1ES DESCftBED HEREIN IS SU&IEGT TO ALl 7HE 7ERMS, '� EXCLUSIONS ANL1 CONRRIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLNIPAS. ��,�..�isa TYPE flF INSUR4NGE aooL suea-, � LI EFF P L ltMRS rcaR wYD ' POLtCY NUA96ER t MMIDP {MMJDOlYYW GENERAI. LIABII.ITY �,' � � ��+CH OCCURRENCE $ 1 CON@AERCIAI GENERAE I.iAEIC(YY I I PREMISES(ca occaesenceY $ - �� I CLAMAS�MA�E �OCCUR ME�EXP(My one person)�& I � PEftSONAi.&ADV MlURY $ I GENERAL AGGftEGnT@ S �GEML AGGREGATE LIMIT APPLIES PER: PRQDUCTS-CONIP/OP AGG $ � I POUCY�jE� LOC I � � IN I AUTOM091LE 1IA81LIN � E&acdCont S i;ANYMti4 �I BODItY3NJURY(perpe�son} S � ��ALL OWNEd � SCHEDULEO I BOOILY INJURV(Par amitlenp $ I � .. � , '�, H R bSAUTOS pUT08��Eb 1 Per amtler+t _ $ � � � � � t � t� '., � ��R�� { OCCUR i I ,, �EACH OCCURRENCE j$ I i '. FXCESS UA8 �i CW�S-bt4pEl j .AGGREGATE ;S OED i P2ETENTION$ i I I ' I ''�� IWRR!¢R$COMPEN3ATION � � � � X j TORY LI�Mt�T3 I I ER� AND EMP40YER$'LIABILtTV YiN � � � � ; aMY afiOPRiETORI1+aEiNEWEtECUnvE i I � �E.1..E4CHACCIDENT �$ SOO�OOO A �OfPiGERlMi:69ER EXCLt#RDx IZ NiA .. '� i t��a�o,�.��wx� � d14005033240113 `OIJOSI13i 1jp8I19 E.LOISEASE-EP.EMPLO�'E s 1d0�000 I uya:.aescnne��apr ��.asensE-ccuicvua+cr s 500,400 ; �aESGRtPT10N OF�PERATkON&bNmv I j i i i i DESCRlPT16N OF 6PERATiONS t tOCATtONS t VEHICLES i�G1 ACORp iDt,Adtlitiona�Remmk%Scneduie,if more space is requitatl} � I I � � CERTfFICATE HOLDER CANCELLA7ION T09PI7 Of Y8iai9tith SHOULD ANY OF THE ABOVE DESCRIBED POIICiES BE CANCELLED BEFORE 1146 RTE .ZH TFiE EXPIR4TION DATE THEREOF, NOTICE W0.L BE DELIVERED M South Yarmouth, t�l 02664 ACCORDANCEWtTHTHEPOI.iCYPFiQVISIQNS. . AU5'H D REPRESENTA I A q _' r �/�.�^ • � �'1986-2910 AC4RD CORP4RATtON. A!I rights reserved. ACORD25(2010/05) The AGORD name and logo are r ' eretl marks of ACORD " �