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Home My WebLink AboutApplication and WC � _ -- _ _ . .C�� a TOWN OF YARMOUTH BOARD OF HEALTH G3C��OMCDD �� * APPLICATION FOR LICENSE/PE��J r 4 " Please complete form and attach all necessary en s bj�D� c mb��"S�I� Failure to do so will result in the retu�lY of�dur appIication acket. HEALTH DEPT. ESTABLISHMENTNAME: �� a�' G'� C T D• LOCATION ADDRESS3�3 RTaC� G✓I�ST y.!-R .v16 u TLJ TEL.#3�A'��r od'%/ MAILING ADDRESS: 3 g3 2?a-Q LJ�S� X�+�'lo� � O�- 6 �3 E-MAIL ADDRESS: (.vyC� C't.t��' Q M t�h�aiv� � OWNERNAME: WFsi �/�-2M oKfl�f ��SGA�6.�'f/O N„�L G�[-�/L CORPORATION NAIv1E (IF APPLICABLE): S.�r+'1� 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 a ach a copy of the certification to this form. �-- — --- -- -- ---� - - - -_ - ----- _ . 1. Pool operators must list a minunum 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. n I I/� 2. 3, 4. i 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 will not use past years'records. You must provide new copies and maintain a �le at your establishment. 1. ` ' a .� 2. r� „ �� PERSON IN CHARGE: • Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. �- ---�— --�� _----- -- _—=2.=��. �4q S� yu c� --- 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 �le 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. �Glh � � � T 2. �v�4�� `9.ri 6 - � �l�`tl 3. ICar�,rt t�li-�— 4. RESTAURANT SEATING: TOTAL# �� -- --- — -- -- �> P z --_ -- _ ___ 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 TRAILERPARK $105 WHIRLPOOL $il0ea 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# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 —<Z5,000 sq.ft. $l50 _FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNT DUE _ $ 3 0.00 •'***PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** -----� ' ADMINISTRATION . Under Chap�er 152,Section 25C, Subsection 6,the Town af Yarmauth is now required to hold issuance or renewal of any Ticense or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TIiE ATTACTIED 3TATE WOI2KEii'S COMPENSATIQN IN8II12ANCE AFFIDA'VIT MUST BE COMPLETED AND SIGNED, OR C�RT. OF INS[JRANCE ATTACHED OR WORKER'S COMP. AFFII3AVIT BIGNED ANI3 A'I'TACHEB Toum of Yarmouth taates and liens rnust be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRSATELY IF PAJD: XES�, Nt7 MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pwposes ofthe Izmitations ofMotel or Hotel use,Transient occupancy sha11 be limited to the temporary and shart term necupancy,ordinarily and custc>marily associated with mntel and hotel use. T'ransient acougants must have and be able to demanstrate that they maintain a principal place pf residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not rnare than thirry(30)days,and an aggregate of not more than ninety(90)days within any six(6)month periad. Use of a guest uniC as a residenoe or dwelling unit shail not be cansidered transient. Occupancy that is subject to the collectian nf Room Occupancy Bxcise, as defined in M.G.L. c. 64G ar 830 CMR 64G, as amended, shall generally be considered Transient. POdLS P40L 4PENING:All scuimming,wading and whirlpools which have been ciased for the seasan must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to openin�. PLEASE NOTE: Peaple are NOT allowed ta sit in the pool area until the pool has been inspected and opened. PO4L WATER TESTING: The water must be tested for pseudomonas,total coliforrn and standard plate count ' by a State certified lab, and submitted to the Heatth Departrnent three (3) days prior to opening, and quarterly thareafter. ' POQL CL03ING:Every outdoar in ground swimming pooi must be drained or cavered within seven{7)days of closing. FO011 SFRVICE SEASQNAL FOOD SERVICE OPENING: All faod service establishments must be inspEcted by the Flealth Deparunent prior to opening. Piease contact the . Health Department Yo schedule the inspection three(3)days prior to opening. CATERING POLICY: , Anyone who caters within the Town of Yatmouth must notify the Yarmauth Health Department by filing the required Temparary Foad Service Application form 72 haurs prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.y2rznouth.ma.us undar Health Department, Da�vnloadable Forrns. FROZEN DESSEI2TS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sampla results submitted to the HeaTth Department. Failure to do so will result in the suspension ar revocation of your Frozen Dessert Permit until the above terms have been met. OUTSID�CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: ' dutdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE.Permifs run annuaIly from January I to December 3 L IT IS YOUR FtESPONSIBILITY TO RE'I'tIRN THE COMPLETED REI�EWAL APPLICATION{S)A1�TD REQUIR�D FEE(S}BY DECBIvfBBR I5,2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN"T'ING, NEW EQUIPMENT,ETC.},MUST BE REPClRTED"I'O AND APPROVE Y THE Bt}ATtD OF F3EALTH PRTOR TO COMMENCEMENT. RENOVATTONS MA QUIRE A S F', LAN. �DATE:�?,J�/�STGIVATURE: � T PRINT NAME& TITLE: � ��'� Rev.11J03?74 WESTY-1 OP ID:DT j°�� CERTIFICATE OF LIABlLITY INSURANCE �TE{MM/ODMlYY) �vzvxa�a THIS CEfiTiFtCATE IS ISSUED AS A IYIATTER OF INF4RMATION ONLY AFtD CONPERS NQ RlGt1TS UPON THE GERTtFiCATE HOIDER. THIS CERTIFICATE GqES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OFt ALTER THE CpVERAGE AFFORDED BY THE POLICIES BEIpW. THIS CERTIfiCASE OF INSURANCE DOES N4T CONSTITUTE A CONTRAC7 BETWEEN THE ISSUING 7NSURERjS), AUTHOR2ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPpRTANT: It the certiflcate hoMer is an ADDITIONAL INStlRED,t#re potig(ies}must be endo�sed. N SUBROGATlON IS WAIVED,subject to the ferms and contlitions of the pa(Icy,certain pollcies may requlre an endmsement. A stat6meM on this cerlificate does not confer rights W the eertiflcate holder in Iieu of Such endo�semen s. � ��G�R N�a 6ea e Nuime -- FiUslnsuronce-Unlon r�oNE ,g08-620-620Q FpXrypj•SOS�B�LO�O�7 . 40 Union Ave. e-rnw ....... �� Framinpham,MA01702 noo y_ ' 6aorgtr Hulma .��i� ur,urseFttslacFoenu+ccav�nc� „�!. . msurseen:Twin City Fire Inaurance Co. �NsunEo Wes2YarmauthUGCChurch �su�ca: 383 Route 26 iNsu�ac: West Yartnouth,MA 02673 — INSURER D: .... INSURER E: ,,,,, NISURER F: � CQYERAGES CERTlFICATE NUMBER: REVISION NUMBER: iH�S IS TO CERTIFY THAT THE POL�qES OP�NSt3RANCE L�S'�ED BELOW HAVE BEEN ISSUED Tp 7HE iNSURED NAMED ABOVE FOR THE POIICY PERIOD INDICA7ED. NOTMTHSTANDING ANY REOUIREMENT, TERM OR GpNDITION OF ANV CONTRACT OR OTHER DOCUMENT IMTN RESPECT TQ WNICH THIS � CERTIFIGATE tdAY BE ISSUED OR MRY PERTAIN, THE INSURANCE APFORDED 6Y THE P4LICIES DESCRIBED HEREIN IS SUB,lEGT TO ALl THE TERMS, EXCWSIONS AND CONDITIONS Of$UCH POLIGES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C WMS. L R POLICY EFF PoUCY EXP l'IR TYPEQFINSURANCE P011CYNiIMBER M MEhNDRYYY LIMITS COMMERCUILGENERALLIABILITV �1CHOCCURRENCE $ . GWM1dS�A1PDE ❑OCCtIR DA S Ee Na¢++rretKe � MEp EXP(My one person) S PERS�NALBADVINJURY S GEN'LAGGREGATELIMITAPPLIESPER: GENERALAOGREGATE S POLICY��a �LOC PRODUCTS-COMplpPAGG 8 JECT S OFHER: CpMBiWED BINGLE UNFi AU1'OMOBILELIA&LITY EaawCenl $ BODILYINJURY{Perperson) 5 RMYAUT4 ALLOWNEQ SCHEDULED BODILVINJURY(ParacciEenq 5 AUTO5 AUTpS PR PERTY DAM� WREDAUTOS AVt0.S Ep tPereaideM�__..._ S $ ��B��g qCWft EACHOCCURRENCE 3 F�cCESSLIAB G�p,IMS-MADE AGOREGATE S DED RETENTIONS $ WORKERSCOMPENSl�T10N STAT T ER amerav�ovEasune�urr 1,806,00 A ANVPROPftIETOR/PARTNER/E)(ECUTIVE YtN N�A OSYVECNN546$ 10/Ot/2014 18/01J2015 E.L.EACHACCIDENT S OFFICEWMEMBER EXCLUpEd! ;��y��t �.i.oisense-�,E��ove s 1,000,00 Ryea,tlesl�ibauntlm E.L.0ISEASE-POLICVLIMIT $ ��pr OESCRIPII NOFtlPERATI NSU9bw DESCRIpT10N OF OPFANTIONS/LOCATIONS I VEHICI.ES(FCORD 101,AGtlMonal Ramarke 9cMtlula,may be attachetl if mwp spaq Is iequiretl) GERTIFICATE HOLDER CANCELLATION T4WNYAR SXOULD ANY OF THE ABOVE pESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRA710N DATE SHEREQF, N0710E WILL BE DELIYERED IN Town of Yartnouth accoRanr�cE wrrN niE�r wccNnsior+s. Route 28 S.Yarmouth,MA 02664 "�"°�°�°�StNT°m� ��' � Cfl i988-2Q14 ACORD CORP4RATIQM. All rights reserved. ACORO 25(2074/p1) The ACORD name and logo are registered marks of ACORD