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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH Q��`�d��° �� APPLICATION FOR LICENSE M1 � 3_ ��' . MAY � 3 PO15 ` * Please complete form and attach all necessar}d t � r 1 S 2014. Failure to do so will result in the refuttf'of ybUr'�p� ation pac t. HEALTH DEPT. ESTABLISHMENT NAME: S v pe� � �rEt� TAX ID: LOCATION ADDRESS: `( I C-rt-�r rz� 28 W, '�InQti,w,Tej en�s TEL.#:I �'-7�5'S 1�5 CD"t(�L MAILINGADDRESS: - S�� °'iS4� rt-3 rz E-MAIL ADDRESS: �lJ%�1 �CI� ��0�• C.9�-� OWNERNAME: 1C+ S�xa�t 1� �*�- CORPORATION NAME (IF APPLICABLE): �)�1 C��*-� MANAGER'SNAME: C,►G�1-l0� TEL.#: MAILINGADDRESS: ul � ✓[� �5' 6�S �7,Mc.Glauh� oU�f1 o7g�3 POOL CERTIFICATIONS: The pool supervisor must be certitied 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. �, CDC �-n� si �- �a�� 2 Pool operatars 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 oftheir certifications to this form. The Health Department wiR not use past years' records. You must provide new copies and maintain a file at your place of business. 1. k-1 S�'ic�2 �� U"�'�'t'<-- 2 � (C `f�l�-Icl�-Q� , 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establislunents 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 file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. L 2. ALLERGEN CERTIFICATIONS: . All food service establishxnents 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 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. 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# i OFFICE USE ONLY I LODGING: � L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE P RMIT# _B&B $55 CABIN $55 / MOTEL $I10 � _INN $55 CAMP $55 1SWIMMINGPOOL$110ea.�(./�_oi31 ��. . _LODGE $55 =TRAILERPARK $105 WHIRLPOOL $110ea I 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: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.ft. $50 >25,OOOsq.ft. $285 VENDING-FOOD $25 � _<25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 I NAME CHANGE: $15 AMOUNT DUE _ $ 220•CO �� •****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*•**• � � ADMINISTRATION Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance ar renewal of any licen"se or permit to operate a business if a person ar company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED `✓ � OR ' WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yazmouth taxes 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 limitations 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 thirty(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 sha11 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 Departrnent 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 area until the pool has been I 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. I 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 Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forxns can be obtatned at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, 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 Pernut 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: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'I'URN � 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 QUIRE A SITE PLAN. DATE: Iµj'r I 3��S SIGNATURE: PRINT NAME&TITLE: �)'�1'7� ��i- ��'�"�_ � Rev. il/03/14 Client#: 16866 � 2SUPERSMO ACORD,� CERTIFICATE OF l .IABILITY IMSURANCE DATE(MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATi )1. ONLY pND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER3 H�ISS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY \MEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT COI 3TITUTE A CONTRqCT BETWEEN THE ISSUING INSURER(S),AUTHORIZED � REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE �OLDER. IMPORTAN7:If the certificate hoider is an ADDITIONAL INSL� 2ED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may-squire an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PROOUCER Dowling&O'Neil ONTACT NAME: Insurance Agency PHONE 508 775-7620 NC No Ezt: q/C,No: SOS7]$�2�$ 973 lyannough Rd., PO Box 1990 E�MAIL noorsess: i Hyannis,MA 02601 INSURER(5)AFFORDINGCOVERAGE NAICN � INSUftED �NSURERA:A��.M. MU�I18I IfI511fafICO COfilPBfl�r iAUM Corp.D/B/A Super 8 Motel �NSUftER B: 3 Algonquin Drive �NSURER C: Burlington, MA 01803 �NSURERp: INSURER E: COVERAGES �MSURER F: CERTIFICATE NUMBER: +��. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE WSURED NAME'D BOUE BFORTHE POLICYPERIOD INDICATEO. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANV CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i CERTIFICATE MAY BE ISSUED OR MAV 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 BV PAID CLAIMS. INSR ADOLSUBR LTR TVPEOFINSUftANGE INSR WVD POLICYNUMeER POLICYEFF POLICYEXP GENERALLIABILITY MMID�/YriY MM1V�O/YYYY LIMITS COMMERCIAL GENERAL LIABILITY pEACH�OCCURRENCE g ClAIMS-MADE ❑OCCUR PREMISES Ea oNcunence E MED E%P(My one person) 3 PERSONALBqOVINJURY g GEN'LAGGREGATELIMITqPpLIESPER: GENERALAGGREGATE $ POLICV jE�T LOC PRODUQS-COMP/OPAGG $ AUTOMOBILE LIABILITY $ COMB W EO SING�E LIMR ANY AUTO Ea amitlenl ALLOWNED SCHEOULE� BODIIVINJURV(Perp¢rwn) $ AUTOS NON-0WNED BOpILV INJURV(Per accident) y HIREDAUTOS AUTOS PROPERTYDAMAGE Pe�dccidBn� $ ❑MBRELIA LIpB OCCUR f � EXCE55lIAB CIqIMS-MADE EACHOCCURRENCE $ �EO FETENTIONE AGGREGATE g A WORKERSCOMPENSATION WMZ80080036422015A A�O'IIZO'IS O4IO'I/ZO� X $ ANDEMPLOYERS'LIABILITY WCSTATU- OTH- ANV PROPRIETOftIPARTNERIEXECUTIVE v�N OFFlCER/MEMBEREXCWDEO? � N/A EL.EACHACqDENT $SOOOOO (Mantlatory in NH) Ifyes,tlescnbevnJer E.L.DISEASE-EAEMPLOYEE $$��O�Q OESCRIPTION OF OPERATIONS balow E.L.DISEASE-POLICYLIMIT ESOO�OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Adtlillonal Remarks Schetlule,it more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certi£cate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER �� CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 'I'I4B R�Z$ THE EXPIRqTION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZEO REPNESENTATIVE �'..,.� ``;�-_._.-,�,. ( 1 7 of 7 The ACORD name and lo o are re istered marks of A ORDB-2010 ACORD CORPORATION.All rights reserved. ACORD 25 2010/OS g 9 #5150975/M150972 NS2