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Home My WebLink AboutApplication and WC ' � a TOWN OF YARMOUTH BOARD OF HEALTH ��L.�^is��'1 I�DD �� APPLICATION FOR LICENS�/P 2815 pEC 1 5 2014 * Please complete form and attach all necessary�nts�y�e :, ber I S 20�4. Failure to do so will result in the rettjrt}of yottt application c � EPT . ESTABLISHMENT NAME: �n� �a e.l TAX ID: �` � LOCATION ADDRESS: � �.t7u� � S �,'�._i"'�� TEL.#: �S -3a8" -33 l b MAILING ADDRESS: " � � `� 7-ta�O E-MAIL ADDRESS: N OWNER NAME: �e o�e.-1� �e�.� CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: � i �I�+� TEL.#: S�C��-33iS MAILINGADDRESS:S�tti 'C2�2 7� � yR�- L"l� f��(o(o �POOLCERTIFICATIONS:DJ�� hot ��n �rv��-'�- S�hc.e Zct3 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. 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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. 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 certificaUon 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 Il\` CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. - i . _ _ 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 applicaUon. The Health Department will not use past years' records. You must provide new copies and maintain a£le 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 Deparhnent 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 USE ONLY ' LODGING: '��. LICENSE REQOIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�IT# '�� B&B $55 CABIN $55 �MOTEL $110 /—�OZ-j � I1V1V $55 CAMP $55 1 SWIMMWG POOL$110ea.�a'w EI�- LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERM[T# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CON'I'INENTAL $35 NON-PROFIT $30 ��, >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 ', —AESID.KITCHEN $80 � RETAILSERVICE: - 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 �, NAMECHANGE: $15 AMOUNTDUE _ $ ZZ�-OO � **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** /�C��IX $ S�i � �/ C`2�{".�u�'5�7 f�s!!�{ , � ADMINISTRATION +� • v Under Chapter 152,Seation 25C,Subsection 6,the Town of Yarmauth is naw required to hold issuance or renewal of any liaense ar permit to operate a business if a person or company daes not have a Certificate of Worker's Compensation Insurance. TFiE ATTACHED STATE WOi2KE:R'S COMPENSATION INSUI2ANCE AFFIDAVIT MUST BE COMPLETED AND SICaNED, C1R CER"I'. OF INSLTRANCB ATTACHED �� OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taates and liens rnust be paid prior to renewal ar issuance o#`your permits. PLEASE CHECK APPROFRIATEI,Y IP PAID: YES IVC} _ � i MOTELS ANA OTHER LODGING F.STABLISHMENTS ' TRANSXENT OCCUPANCY: For purposes oPthe limitations ofMotel or Hotel use,Transiant occupancy shall be limited to the temporary and shart term occupancy,ordinarily and oustomarily associated with motel and hotel use. Transaent occupants must hava and ba able to demanstrate that Yhay maintain a principal place of residence elsewhere.Transient occupancy shall generally refer ta continuous occupanoy of not more than tivriy(30)days,and an aggregate of not more than ninety(90)days w'rthin any six(6)montki period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject ta the collection of Room 4coupancy Fxcise, as defined in M.G.L. c. 64G or 830 CMR 64G,as amended, shall generally be considered Transient. POOLS POt}L 4PENIlYG:All swimming,wading and whirlpools wiuch have been closed for the season rnust be inspected by the Health Deparqnent priar to opening. Contact the Health Departrneiat to schedule the inspection three(3) days priar to opeaing. PLEASE NO'I'E: People are NOT allowed to sit Sn the pooi area until the paol has been inspected and opened. I'OOL WATER TESTING: 'I�he water must be tested for pseudpmonas,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. PQOL CLOSI�'VG:Every autdoor in ground switnming pool must be drained ar covered within seven(7)days af closing. I FOOD SERVd�E SEASONAL FOOD SERVICE OPENING: Alf food service establishments must be inspected by the I3ealth Department prior to opening. Ptease contact the Health Department to schedule the inspection three(3) days prior to opening. CATERING POLICX: Anyone who caters within the Town of Yurniouth must notify che Yarmouth Health Department by filing the reqmred Temparary Foad Service Application farm 72 haurs priar to the catered event. These forms can be obtained at the Health Aepartment,or fram the Town's website at www.varmouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Prozen desserts rnust be tested by a State certified lab prior to apening and rnonthly therea8er,with sample results submitted to the Health Departrnent. Failure to do so wili result in the suspension or revocation of your Frozen L?essert Permit untii the abave terms have been met. 4UTSIDE CAFES. Outside cafes(i.e.,outdoor seating with waiter/waitress servica),must have prior approval from the Board of Health. OUTDOOR COIJKING: Outdoor cooking,preparation,or display of any food product by a retail ar food service establishment is prohibited. ; NOTICE:Permits run annually from January I to December 31. IT IS YOUR 12ESPONSIBILITY Td R�TI.IIZN ��! THE C4MPLETED RENEWAL APPLICATION(S}ANI}REQUIRED FEE(S}BX D�CEMBER 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PANTTNG, NEW BQUIPMENT,ETC.},MUST BE REPC?RTEI}`1'O AND APPROVED BY THE BOAR.T3 QF HEALTH PRT4R T'O COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE:—��i;�-.�--SIGNATIJRE: J�-=' � ' PRINT NAME&TITLE: -�. '�"� 1'' ft�. �iimrsa � � i __ -- - _ . , . -_- ------- -- ---__ ' Client#:283188 PINEKNOTMO ACORD,� CERTIFICATE OF LIABILITY INSURANCE °"�""""'°°'"""" �uos�so�4 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 CONSTIME A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTFICATE HOLDER. IMPORTANT:H the certfiwte holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WANED,subject M fhe terms and wnditions of!he policy,eeRain policies may require an endorsemeM.A statement on this eertificate does not confer rights to!he certificate holder in lieu of sueh endorsement(s). PR�UGER ^`� Anita Aheam HUB Intemational New England P"�, �:508-359d152 N,; 508359-2114 4 West Mill Street e�a� Medfield,MA 02052 "OD��' - SOS 359-4151 ��ISJ�FOROBlGCOVERAGE wucx iNsu�rs n:NorGUARD Insurence Company 31470 WSURED Pine Knot Motel IN9URER B: Deboreh SWnley dba wsurseR c: 890 Main Street MSURERD: � @13URER E: Bass River,MA 02664 MSURERF: COVERAGES CER7IFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE FOR THE POLICY PERIOD - � . . 1NDICATED. NOPNIFNSTANDING ANY.RF.6IUIBEAAENT, TERbt pR-CpND1TION�OF ANY CQNFRACT�R13ItlER.DOCUM�NT WIIH RESPECT TO WHICY..TNIS � 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 PAI� CLAIMS. - � LTR TYPE OF INSURANCE �� PoLICY EFF POLICY IXP �� INSR WVD POLICYNUMBER WD UMRS GENERALIJABILfTY EACHOCCURRENCE $ COMMERCIALGENERALLIABILRV P��yT�E�� $ CW MSMADE �OCCUR MED EXP(Arry ane person) $ PERSONALBADVINJURV $ GENERrLLAGGREGATE $ GENLAGGREGATELIMITAPPLIESPER PROOUGTS-COMP/OPAGO 8 � POLICY �E� LOC � S . AUfONOBILELIA&LITY COMBMEDSINGLELIMR � � Ee acatlmt ANYAUTO - BODILYIWURV(Perperaon) $ ��Ep S�CTH�ULED BODILVINJURV(Peracatlmt) $ NON-OWNED PROPERTY DAA1HGE HIREDAUTOS �p�Tpg ` Peracdtlenl $ E UMBRELLA LIAB pCCIIR EACH OCCURRENCE $ E%CESS W18 CLAIMS-MADE � AGGREGATE S OEO RETENTION$ § A wonKErsscoMvexsnnoN DEWC553823 4/25/2014 WCSTA7IY� . OTH- nnoernrwrEasunearrr v�N 04(25@01 X ANYPROPRIETOR/PARTNEWFJ(ECIfrIVE E.L.EACHACCIDENT E�OOOOO OFFICERIMEMBEREXCIUDED? � N/A (Ma�WataylnNH) E.L.DISEASE-EAEMPLOVEE E�OOOOO ��.a��u�� E.LOISEASE-POLICYLIMIT s500,000 DESCRIPTION OF OPERAT10N5 bHow � DESCRIPTION OF OPERATONS/LOCATIONS/VEHIGLES(Attach ACORD 107,Atltlitional RemaN:s Schetlule,H mpre apaca is reqWrttl) Operations Usual to the Business of the Insured CERTIFICATE HOLDER CANCELLATION Town of Yartnouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE�CANCELLED BEFORE THE EXPIRATION DATE TMEREOF, NOTICE WILL BE DELNERED IN ROUSE ZH ACCORDANCE WRH THE POLICY PROVISIONS. Board of Health South Yarmouth,MA 02664 AIf�HOR12ED REPRESENTATIVE - OO 7988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/OS) � pf� The ACORD name and logo are registered marks of ACORD . #51263545/M1120220 JT002