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Home My WebLink AboutApplication and WCr � TOWN OF YARMOUTH BOARD OF HEALTH � °"� '� � � APPLICATION FOR LICENSE/P�E IT -2015 � �E� �9 2�14 ""' * Please complete form and attach all necessary doCum�s bylDecem er Failure to do so will result in the retum;of y�ur applicahompa �DEPT. ESTABLISHMENTNAME: f�J�cr 5<r��.� c� c�,.c c�,..� } Zs��-J�� TAXID: LOCATIONADDRESS: Sa� Fo� ,i lLaGdl i,.r "�w^.,.�� nA TEL.#: SaS--S�B- >'��C MAILING ADDRESS: g� e E-MAILADDRESS: ea. ..,,,, �. e cscc: .a- OWNERNAME: ��J- � � ,..-c , nF c�` 4s a -I.s\w,1�, , � t. CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: fJa�c t'�v �\-, p R,�� .. P'`�..�ti v TEL.#: SaS � 3ti��'��t+�u k�io� MAILINGADDRESS: iss �� '�� Sw1� ��-^.> �''�4 U14t,o 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 fo _ _ _ __ __ __ _ L _ - — - ---- __- _ L --- - Pool operators must list a minimum of two em ees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resusci on (CPR), having one certified employee on premises at all times. Please list the empioyees below and att copies of their certifications to this form.The Health Department will not use past years' records. You st provide new copies and maintain a file at your place of business. 1. 2• 3. 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ail 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 aad maintain a file at your establishment. 1. ISL�� urr 2. �at`� 1 ��\L. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. �: I1Y�r _�_�___ L. �'� � ALLERGEN CERTIFICATION : 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. �TF: 1 `Unrc 2.. r\�-1 / �c.* 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 a11 times. Please list your employees trained in anti-chokmg 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 �le at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# $P��3��f3N�--- —- ---- - — — _ . - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $ll0 —INN $55 CAMP $55 SWIMMINGPOOL$110ea. LODGE $55 TRA[LER PARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 —CONTINENTAI, $35 �NON-PROFIT $30 �f,s b7O >100 SEATS $200 COMMON VIC. $60 WHOLESALE $SO — — —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT 1! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.8. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $I10 NAMECHANGE: $15 AMOUNTDUE _ $ 30.00 � •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'•*'* ADMINISTRATIf1N Under Ch�,pte; 152, Section 25C, Subseotion 6,the Town of Yarmoufh is now required to hold issuance or renewal of any license ar perth9Y to operate a business if a persan or compauy daes noi have a Certificate of Warker's Compensation Insurance. THE ATTACHED STATE WOI2K�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED ANIIr SIGNElI, Lli2 CERT, OF 1NSURANCE ATTACHED ✓ OR �-- WQRTf.ER'S COMP. AFFIDA'YIT 5IGNEI7 AND ATTACHF.D 7bwn of Yarmouth ta�ces and liens must be paid prior to renewal ar issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: XES `,/ N(7 NI+DTELS ANI}01'HER LODGING F.STABLISHIYIENTS I'RANSIENT OCC7ITPANCY: For purposes of'the limitations ofMoteI or Hotel use,Transient occupancy shall be limited to the temporary and shart term occupancy,ardinarily and ettstomarity assaciated with motei and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place pf residance elsewhere,Transiant occupancy sha11 general ly refer to continuous occapancy of not more than thirty(30)days,and an aggregata of not more than ninety(40}days within any six(6}month period. Use of a guest unit as a residence ar dwelling unit shall not be considered transient. Occupaiacy that is subject to the collection of Roorn Occupancy Fixcise, 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 far the season rnust be inspected hy the Health Department prior to opening. Contact the Health De,pa.a•tment to schedule the inspection three{3) days prior to opening. PLEASE NOTE: People aze NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must ba tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submiYted ta the Health Department three {3) days prior to opening, and quarterly thereafter. POOL CLOSTNG: Every outdoor rn graund swirnming pool must be drained or covered within seven(7)days of closing. FOOD S�IZVICE SEASONAL FOQD SER'VICE OPENING: All food service establislunents rnust be inspected by the I-iealth Departmeizt prior to opening. Please contact the Fiealkh Department to schedule the inspection three (3} days prior to opening. CATERING POLICY: Anyane who caters within the Tawn of Yarmouth must notify lhe Yazmauth Heaith Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be ohtained at the Health Department,or fram the Town's website at Fvww.yannauth.ma.us under Health Deparrinent, Downloadable Fornns. FROZEN DESSERTS: Frozen dasserts must be tested by a State certified lab prior to opening and monthly thereaftar,with sarnple results submitted to the Health Departrnent. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit untiI the abave terms have been met. QUTSIDE CAFES: t}utsifle cafes(i.e.,autdoor seating with waitertwaitrass service},must have priar appraval from the Baard af Health. OL4TDOf1R COOKING: 4utdoor cooking,preparation,�r display of any faod prodact by a retail ar faod service establishment is prohibi#ed. NOTICE. Permits run annually from January 1 to December 31. IT'IS YOUR RESPONSIBILITY TQ RGTURN THE COMPL�TBD RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 1S, 2014. ALL RENOVATIONS TO ANY FOOD �STABLISHMENT, MOTEL OR POOL {i.e., PAINTIN(i, NEW EQUIPMBNT, ETC.),MUST BE KEPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. REIVOVATIONS MAY REQUIRl:A SITI:PLAN. DATE: t� ��co�rH SIGNATURE: �.- `� PRINT NAME & TITLE:_ £�.,�; c I'��N.a��:a;,., QcwS�,,., j'��..,�,� Rev. 1 UO3/14 Ri�ht£ax C3-2 8l1512d14 �:Q0 :31 AM PAGE 2/002 Fax SarveY : ; ��`�`�` CEFtTIFICATE OF L(ABILtTY IIVSURAIVCE nnre�Mmvoomrrn �T��R1'IFICATE IS ISSUED AS AMATTER OF MFORMATION ONLY AND CONFBRS NO RIGHTS UPON THE CERTIFICA7E HOLDER. THIS CERTIFICATE D6ES N4S AFFIFtMAT1YELY 4R NEGATNELY AMENO,EXTEND QR AlTER TtS£C4V6RkGE AFFOR6ED BY THE P011CIES BELOW. THIS CGRTIfICATE DF WSURANCE DOES NOT CQNSTITUTE A CON7RACT BETWEEN 7HE ISSUING INSURER(S),AUTHORIZED REPRESENTATNE OR PR ❑UCER AND THE CERTIFlC TE H ER. (MPOpTAM;If the certlflcate holder Is an ADPiTIONAL INSUREp,the,policy(les)must be endersed. If SUBROGATION IS WNVE�,subject to the terms and conditlons of the poticy,certain policies may require and endorsement A statement Qn this certifteate does not confer rfghts ta the ertificate hatder In deu af such endorsemen s. PRODUCER GONTACT NANE: HItS INTL NEW ENGL.4ND LLC - PHONE F/+K 29y BALd,ARDV ALE STREET {A/C,No,Extg t��aa?: EAW l WILMINCiI'ON,MA 01637 � ADDRE55: � ��u INSURER(5}AFFORDRiGGOYERAGE NAIC# � INSUREO INSIIRERA: ftARTflaRDlINDF]tRRtTTSRSMSORAN�CGMPN�' �ELDER SERVZCES OF CAFE COD&TKL ISLANDS INC tt�7REa e: INSUREB C: � INSUREfl D: (8 RT 134 INSUflER E: �`- SO DEhRvZS,MA 02fi6Q � �NSURER F. . COYEBAGES CER'ttE�ATENUMBER: REVi510NNUbiBER: � 615 CERTIF�YTHATTHEPqLILYESpFM511H4NCEI�SfE08ELOWHAVEBEENISSOFDTOTHEINfiUFE�NAMFDAHOVEFOliTHF.P�LiCVPEBIDOWUICATF➢.N�TWrtH5TAN�MG ANY FEqUIFEMENT;TEAM Ofi CpN�R10N OF ANY CONTqALT Qfl�THEfl DOCUMFM WITH flE9PECT TQ WHICN THIS CEFIIFlCATE MAY BE ISBLIF�Ofl MAY PEfiTNN.THE IN9UFANCE fifFOA6ED 6YTNE POliGESOF.SCRIBEU t�EiEIN b^StJ&7ECT SOACtT!¢TFAb{9,IXCtU9WiS ANO CONai(%)R'S OF SUCH POL�tES.IiNM+�iWVN MdY HAYE6EEM IiEDUCED 8Y PN6 CLAIMS p19q bQD S POGICYffFDATE POI�YE%POATE LiA iYPE Oi QlSURANCE � L fl PDLIGY NUMBFA (MMIUMYYVY) (M6Tll0\YYYYj LIMIf6 GENERALLIABlLlTY CHOCCt1ftftENCE � g COMMEFCIALGENERALLIABILITY AMAGE70RENTED $ GLAIMS MADE �OCCUR. REMISES{Ea ocvxrencej EDIXP(Anyonep�san) $ ERSONAI&AOV IN3URY $ GEN'L AGGREGA'fE LIMIT APPLIES PER: FNERAI.AGGREGATE $ POlK:1' �Pft6.7ECT�l� . RODUCi'S-COMPIDPAGG $ AtiTpM681LElJABILITY �pdePlEDSiNGLE $ hNY AL7To LIMR(Ea accideM} AILOWNEDAUT05 SOOILYM.lURY $ . SCHEDIJLE AUTOS {p�P��} HIREDAU705 BObILYlNJl1RY & � p¢r acc�erk} NON-OWNEDAt7tOS PROPERTYDAMAGE $ {PeraccidorA} UMBRELIALidB OGCl7!i EACHOCCURftENCE $ EXCESS LIA6 CLAIMS-MADE AGGREGATE $ � DEDUCTiBLE � $ � RETENTION S � � WORKERS COFdPENSATfON ANO �+ WG STAMOflY a�ER EMPLOYEP'S LIABILtTY yM 116�d727P367-14 07/012014 07/pi/2015 uMRs PNYAfloPEflITOPJPARTNE�EXECUTIVE �WA Et.EACHACCIDEt3t $ 1,00�,�0 oFFlpEMaEMeEqE%c�udEDz E.L,DISEASE-EAETAPLOYEE $ 7,p00,000 (MantlazorylnNH) . ttme.aesaweuMe[ � EL.DiSEASE-PQClCVlIMfi $ ��p0�,000 DE5CRIF(IpN OF ll'+ERATIONS bdow DESCRIPTIONbp�PEHAl1ON57LOCAl10NS(YEI-IlCLES(RESTftiCTlONS(SPECIALlTEMS � THIS REPTACES ANSPRIOR CfiRTIFfCATE iSSL�ED'ttJ 1'HH CPR'tiFTC.4TEHtR.DER AFFECl'WG W DR[�F.S COMP COVfiRAGE CERTlFICATE HOLAER CANCELLATION SHOIIl.D ANY OF THE ABOVE DESCRIBED POIJCIES 6E CANCELLE� BEFORE 7HE EXPIRATION DATE 7HEREOF,NOl7CE WILL BE bELiVERE6 IN ACCOROANCE Wi7H 7HE POUCV AiiQVIStOt�fi.'..' � . Al77HOflREO REPRESEMATIYE ��.�, +��-`y� e t*S'�Kx'� .ti � � ,..�._.._ ""' . �. ,t ACQRD 25(2070l�5) The ACORD name and logo aze registered mazks oE ACORD Y98&-20t0 ACORD CQRPF)f£A'El'U'hI:'�iS7i4f fits resecved.