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Home My WebLink AboutApplication and WC ' ,a TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PE� T -�2015 ��C L�C M�DD `� * Please complete form and attach all necessar}+doc�ents b�y�e� ber �(��4 Failure to do so will result in the retum of your applicatiot�p ket. + �a ✓ , . ESTABLISHMENT NAME:�-�5 ss ��o �u,� ' iccr.=� s. TA D• LOCATION ADDRESS: /2�� 4in: �i �c H* .� �Rrno rr�� ?�9 TEL.#: � - -ZZZ� MAILINGADDRESS: �7ui /�K ' Si-��,e ' /J� /nA-� rohl �r.!/r °�`i.�� Zty� E-MAII.ADDRESS: [. G S s� e �o� c a M � OWNERNAME: P��c �3 Fc-,rGu CORPORATION NAME (IF APPLICABLE): �/3 S S� l'ov/> ��'�i��-�� MANAGER'S NAME: SG,�J �E=,�,+��tyD TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certi�ed 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. N � __ _ __ _ _ - z. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cazdiopulmonary 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. i. �� 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 wi►1 not use past years'records. You must provide new copies aad maintain a file at your establishment. /� 1. 1�'o � /��/�iv/�/�� _2_ ��V ily (��/l�µ-. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1, S�to � �1:1✓'.�rtr� 2. �'l,`Y �^ 3� :� 1;�., 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 Sanitazy 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 Tile at your establishment. (� 1. >Co� r 2NR✓�✓� 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. RESTAURANT SEATING: TOTAL # I � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 [NN $55 CAMP $55 SWIMMINGPOOL$110ea. _LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �15—C%�� CONTINENTAL $35 NON-PROFIT $30 >I00 SEATS $200 �COMMON VIC. $60 � � rj--�(�O _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: - LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,OOOsq.ft. $I50 =FROZENDESSERT $40 —TOBACCO $110 NAMECHANGE: $IS AMOUNT DUE _ $ l '�J- OO •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** "`� (�b'� �%�Ir-�ltl�lo5 llj��t�' � � ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal af any license or permit ta operate a businass if a person or company does not have a Certificate qf Worker's Compensation Insurance. TTiE ATTACHED ST'ATE WOiZKER'S COMPEN3ATI41ti INSURANCE AFFIDAVIT MUST SE CONIPLETF".D AND SIGNED, OR � CERT. QF iNSURANC�ATTACHED OR WORKER'S COMP. AFFII7AVTT SIGNED AND ATTACHED Town of Yarmouth tases and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TIiANSIEN'C OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be lirnited to the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Tzansient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient oocupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate o£not more than ninety(90)days within any six(6)mcmth period. Use ofa�;uest unit as a residence or dwelling unif shall not be cansidered transient. Occupancy that is subject to the colTectian of Roam Occupancy Excise, as defaned in M.G.L. c. 54G or$3Q CMR 64C"x,as amended, shall generally be considered Transzent. POOLS POOL 4PENING:All swirnming,wading and whirlpools which have been ciosed for the season must be inspected by the Health I�epartment prior to opening. Contact the Health Department to schedule the inspection three(3) days priar to apening. PLEASE NCJTE: People are NQT alloweci fa sit in the pool area until the poal has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudamonas,total coliform and standard plate count by a State certified iab, and submitted to the Health Department three (3) days prior to opening, and quarterIy thereafter. P(}QL CLOSING: Every autdoar in ground scvimming pooi must be drained or caverefl within seven{7)days af closing. FOOD SERVICE SEASONAL FOOD SERVICE Ok'ENING: All food service establishments must be inspected by the Health Depariment prior ta opening. Please contact the Health Department to schedule the inspectian three (3)days prior to opening. CATERiNG P4LIC'Y: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filin� the required Temporary Food Service Applicatian form 72 hours priar ta the catered event. These forms can be obtained at the Health Department,ar from the Tawn's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSF.RT3: ' Frazen desserts must be tested by a State cercified lab prior to opening and rnonthly thereafter,with sample results submitted to the Health Department. FaiIure to do so will result in the suspension or revocation of your Frozen Dessert Permit untii the abave terms have been met. OUTSID�CAFES: Outside cafes(i.e.,outdoor seaUng with waiter/waitress service),must haue prior approval from the Board ofHealth. ()UTDOOR COOHIIVG: Outdoor cooking,prep�ration,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January I to December 3 l. I1'IS YOUR RESPONSIBILITY TO RE`I'tIRN THE COMPLETED RENEWAL APPLICATION{S)AND REQUIRED FEE(S}BX DECEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e, PAINTING, NEW EQUIPMENT, ETC.}, MUST BE RBPORTED 1'O AND APPI20VED BY THE BOARD OF HEALTH PRIQR T'O COMNIENCEMENT. RENOVATIONS MAY RE IRE A SI PL . L7ATfi: l 2 ��/�' SIGNATURE: ��,�.��! � � PRINT NAME&TITLE: �4-LP� t/' 1�� /�.f�,��Z!'� Rev.1 U031]4 ,acoRo° CERTIFICATE OF LIABILITY INSURANCE DATE�MMIDDMIYY) �� ii�24�zoi4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT APFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFPORDED 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 certiflcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the tertns and conditions of the policy,eertain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemenqs�. PRODUCER NAMEACT Skleii]r MCNdll]� DFM Insurance Agency, Inc. PHONE , (508)540-4555 F'ix csoe�sao-9zss A/C No: 668 Main Street ADpRE :aherry@cape.com � MSURER S AFFOROING COVERAGE NAIC k Falmouth IIl� 02541-0656 INSURERA:V0LILLOIIY. M11tUd1 Insurance Co 6016 INSURED INSURERBNOLGVARD Insurance Co. 31470 L B J 55 FOOD SERVICE INC DBA D'ANGELO INSURERC: 341 I.P,KESHORE DR INSURERO: 341 Lakeshore Drive INSURERE: MAR3TONS MILLS I� 02648-1327 INSURERF: COVERAGES CERTIFICATENUMBER:�L3452e509a REVISIONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH 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 SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS. . INSR POLICY EFF POLICY EXP �� 7VPE OF INSURANCE POLICY NUMBER MM/OO/riVY MM/DDIYriV LIMI75 GENERAL LIABILITY EACH OCCURRENCE $ 1�OOO�OOO X COMMERCIAI GENERAL LIABILITV A E T RENTED SOO�OOO PREMISES Ea ocwrzence $ A CLAIMS-MADE �OCCUR P71036569 /1/2014 /1/2015 MEDEXP(Myoneperson) $ 5�000 PERSONAL 8 ADV INJURV $ S�OOO�OOO GENERAL AGGRECaATE $ 2�OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ Z�OOO�OOO X POLICV PRO- L� $ AUTOMOBILE W181LITV COMBINED SINGLE LIMIT Ea accitleM ANV AUTO BODILV INJURV(Perperson) $ ALLONMED SCHEDULED BODILVINJURY(Petecr,kerrt) $ AUTOS AUTOS HIREDAUTOS NON-ONMED PROPERTYDAMAGE $ AUTOS Per accitlent 3 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1�OOO�OOO A EXCESSLIAB CLAIMS�AADE AGGREGFTE $ DED RETENTION$ U11002291 /1/2019 /1/2015 $ $ WORKERS COMPENSAl10N x N/C STATU- OTH- ANDEMPIOYER3'LIABILIT' ��N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIUENT $ SOO OOO OFFICER/MEMBER EXCLUDED? � N�p (MantlaWryinNH) 433996 /1/2014 /1/2015 E.I.DISEASE-EAEMPLOVE S 500 000 Ify es,tlescnbe uMer OESCRIPTION OF OPERATIONS Oela.v E.L.OISEASE-POLICV LIMIT $ SOO OOO DESCRIPTON OF OPERATIONS I LOCATIONS/VEHIGLES �AMndi ACORD 707,AtlGtional Remarks Schetlule,If more epaee is requireE) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOvm Of Y3TIDOuth ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Board of Health 1146 N. Main St. AUTHORIZEOREPRESENTATVE Yarmouth, MA 02644 D MeCarthy/SMCNAL Qs.-.�_P� a�� ACORD 25(2010/OS) �O 1988-2010 ACORD CORPORATION. All rights reserved. INS025 mm�ns m T�,e ecnwn..�..,e,..,�i,,,.,,„e ro,,;a.e,„,�me�4c�ni ACflRfI