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Home My WebLink AboutApplication and WC S�.c�F� � � � TOWN OF YARMOUTH BOARD OF HEALTH ��p�r�p = APPLICATION FOR LICENSE�'� . -r-2 �k. `"� * Please com lete form and attach all neces ` "�� o �isn��i.Ilec`� be�� 19'�I�D�J� Fail e to do so will result in the retur�n of�i'�p��ica�� cket. HEALTH DEPT. ESTABLISHMENT NAME: � l 6U� TAX ID: LOCATION ADDRESS: TEL.#: a MAILING ADDRESS: � 2 2 E-MAIL ADDRESS: � —2 C�" OWNER NAME: � CORPORATION NAM (IF A P ICABLE): MANAGER'S NAME: TEL.#: � � MAILING ADDRESS: 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 _ _ __ � ---- 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. 2• PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l, _ _ 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. l, 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# OFFICE US�E 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 PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ! 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 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 _ $ j�'S.�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter T52, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal of any license or permit to operate a business if a person or company does not have a Certificate of Warker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ox '�d ��X WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taYes 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 ofthe limitarions 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 thirly(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 azea 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 priar to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yarmouthma.us under Health Depariment, 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 waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: _ __ _QuTdoor cookiug,�rPparatiQn or_display of any_ ood ron duct�_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: 1�'' S — �A(G� SIGNATURE: PRINT NAME&TITLE: ' � cJ t Rev. 11/03/14 ' �� 4341..—F, i A�r-(�J� 2 6. 2�1� 1�:(�C AM, QnT�tn�r�oorrrrry c�tti 1 (FICAI'E C'►F t..lAB1�.ITY INSURAIdC� ��zs�zoi5 TNts CER'nF�CATE�S �88UE0 AS A MATTER OF INFDRMA'fiON ONLV ANp COM�ER9 NO RiGH75 UPON TNE GEF�TIFICAT� HDLb�R. TH�S CERTIFIGATE OpE3 NQT AFFIRMATIVE4Y OR NEGATtVELY AAAENQ, E7fiENq OR'AL7ER TNE COVERAGE AFFpRDEb 8Y TNE PpC,iCIES BELbw. THIS CBRTlFIGATE OF INSURANCE D0�8 NOT CdNSTITUI'E A C4N7RAG1' BETWEEN '(�E lSSUlhG INSU1?ER(S), AUTHO�IZED REPRESENTATIVE Oi2 PRQ�UCER, ANb THE CERTIFICATE HdLDER. IMPORTANT; If tne certiflcate halder IB an ADDIYiONAL INSURED,thg poiicy(!es)must b6 endorsetl. If SUBROGATION►S WAIVED,subJact tv ^ the terms antl canditbns of tha pnllcy,CBrtafn p0ltCieS m8y repu�te an endprs,gment. A dtetemant o�thl8 cert�flCate doe9 nOt confgr rlghts to th9 toAlflcaia hoider in iieu of auch endoreament(s�. PRODUCER A ' NAME: MCSHEA INStJR7�PiCE AGENCY _ vuvw� F 1550 Falmt+uth l�d 5te � << ��`Y"�'"" . c N (508)420--9011 �uc r�:(508)420-9010 �'� C� {',-;.U ��J�S L,�j nnoR�ss:mi.chele2@mcshesinsurance.com Cen�ervil].e, MA 02632 �oo C 7 RID 1'?''"a 7 �' ��+ �N$UKER(8f �{VKOADtNCt C6VERAaE NpIGP INSURED Jesk Ga�e, INC �,,, .� ' r+vsU��Rx��ational Graz�ge Mutual Zns Ca. G�.er� Roy St;rks ��""`�'g� ��> INSURER 8:�h�' Har� ord Insurance Company 39 ,7oe L.ie��oln Rdad +NsuReRe: West Harwich, MA 02671 �NSURE!{D: � INSUkER E: INSURER f� GI3V�REIG�S GERTIFICATE tVUMB�R: REVtSION NUMBER� TH15 IS Tp CEftTIFY TNA7 THE P4LlClES OF IN$URANCE �,{$tEQ 9EL(JW HAV� �EEN (SSUED Tt?TNE iNSURED NRMEC}AB4VE F4R TNE PC7ltCY A�R10i3 ►NptCATED. NOTWITHSTANDING ANY REQIJIREMENT, TERM OR CONDITION OF ANY CONTFZqCT OR pTHER DOCUMENT WI7H RESP�CT 70 WHICH THI$ CEftT1FIGA7E MAY aE l9��El} C�R MAY PERTAIN. THE IMSURAt�IGE qFFORD�D BY T}�� PC7LICIE$ DESCRIp�D HEREIN IS SUBJ�CT TQ At� THE TERMS, EXCLUSIpNS AND CONbITIO�JS OF SIICH POl.ICIES.LIMITS SHOWN MAY HAVE 6EEN kEDUC�p 6Y PAID CIAIMs. �R '�"YPE C+F IroSURANCE ��y� P4Lt�Y NUMBEft M aD� MMm r E U0.A1T$ GfiNERAL tiA9iLiTY EACM OCCURaervCE S l,OOQ,aOQ x G�3Mrt+iERGIAI GENERAI LtANILITY PREMfSES �e ocCuncnae s �,D00�,000 CLArMS.MAdE �OCGUR ` MED EXP(Any on�peraon) , S S,O,(ti�Q A SF{�3465J e1�.fll�.�el�.4l1 pERSONA�R.AOV iNJU�Y S �r 0��i�dd GENERRL A�CyREGATE 3 �� 0 r�� GEN'L AGGR�GAT�UMIT APPLIES PER: PRfJDUGY&-COMPtpP AGG $ �t 04 Q.�� POLtCr °R°' �oc s AUTOMOBILE LiAgI�IT`( COMBIMED&INQLE UMfT � (Ea eccidont} ANYAUTl7' @pOt�Y tPt.lt�RY(Per per5on) S � Atl(7trlMED AUTOS fll7DILY INJURY(per eccWenl} 3 SCHEDVI-EQ At)T43 . � vRO�'ER7Y onMnGE � NIRED AUTOS (Par acci0ent} NpN-4WNEO nUTOS � � ,UMBREI.(,,q LIl48 QCCUR � EAC,N {}GGURRENGE. � EXCESS U4q GtAIMS•MRDE A6GREGATE S 6E4l1CTIHLE S RE7ENT�DN S $ u++URKEftS C4MVENS4T1dN �GST - Oik- ANO EMP�pYEIi$'UA811.IFy � RY LIMITS E '� AMY Rk6PRIETPRtPARTtdERtE7CEGUTiVE. YIN �p��n/+N�'7A',1 612�6J2D1.3 61�6J242d S�� '�� n �� t�+ E.t,E4CMACCioEN� 9+ i oFcicewr+t��eEA EX�LUDEDT � NIA 6/26/20ia 6f26/2415 (MB�deivey U NN) E.�.DISEA��-F��MPLOY�� S �5�Q�0�� IIy89,dBE1Cf�bbU�d9f CQA A!t!t OE$GRIPTION OF pPERATlONS befaw E.�.DtSEASE_PdIICY�IMI7 S +� v��vir �EBCFiiP710N OF pP€RqT10NS/LOCATIQNS/VENICLES (Allach ACORD tUt,Addi�iona)R9merka Schedule,il mare upr,ce i,rpq�ired) ;ERTiFt�ATE t�o�aER CRNC��tAT�aN Bt�a�d O� K6$1'th SNOULD ANY CIF TNE ABOVE pESCFZIBED POUGIE$ BE CANCEILED BEFORE 1196 Raute 2� TH� EXPIRATIQN DATE THEREpF, NpTtCE WILL SE D�LIVERED iN Sou�Ch Yarmau�h, MA QZ�E�S�iI ACCdRDANCE WI7N TNE POL�CY PROVISIOhlS. AUTHORIZE�a�ENTATI,� " ,,.�,� 1 �1989-2409 ACORQ CORP4RATiC?N. AIE rights resented. CQRD25(2009/09} The ACORQ nflme and logo are r8gistered marks Of ACORD