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Home My WebLink AboutApplication and WC ' , C-LAEQ SVC$• - yAK. ' _ � � TOWN OF YARMOUTH BOARD OF HEALTH Nu,-2a�oN S trE � � APPLICATION FOR LICENSE/PERNIIT-2 1 � _ .'��(�yro �_.._ � � � � * Please complete form and attach all necessary documen s b7�pcp b�'�5�2d32 ��' �° � � Failure to do so will result in the return of your applicat�on packet.��v 3� ESTAi3LISHMENTNAME:EIder Services of Cape Co�sl�idthP rsland£AXiD: `" ' • _ LOCATION ADDKESS: 528 Forest Rvenue, Yarmouth, Ma 7'EL.#`.50�=398-5DbU`_= ;v1AILlNGAI�DR�SS:__ � ou e , ou ennis�FTa�23�� ____ _ L�WNERNAME: Elder Services of Cape Cod and_the Islands, Inc.___ _ COKPORATION NAME (IF APPLICABLE): _ — MANAGER'SNAME: Gail Murrav, site Coordinator TEL.#: 508-3q8-5n6n _ MAILING ADDRF,SS: Kimberly Manta, Site Coordinator 508-398-5060 POOL CERTIFICATIOIvTS: 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:o this form. _�_ _ _ � _ i Pool operators must list a minimum of two employees cu�rently certified in basic water safety, standard First Aid and Community Cardiopulmonar� Resuscitation (CPR). Please list these employees below and attach copies of employee certifications to this form. The Health Department wi11 not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• � 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at ]east ove fiill-time employee who is cer,ified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Estabtishme.nts, 105 C:VIIt 590A00. 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. �. fail Miirrav Cito fn d.inatar 2• v;'"—nT�TT � — PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. _�i1 .Murr:x,_Meals on Wheel�_Si_��s�os-�-_—_�_-_?._Kimharl"��.r.,ge�i.a�L�?.�i�a�i-te_Ca.Fr-. -- HEIMLICH CERTIFICATIONS: , All food service establishments with 25 seats or more must have at least one emp�oyeF trained in the Heimlich Maneuver on the premises at all 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 file at your place of business. 1. Gail Murray, Site Coordinator 2.Kimberlv Manta.�.it�oordinatnr 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _�pg�N �55 _MOTEL $55 � I� $55 _C,qMp $55 _SWIMMING POOL $80ea. � LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $SOea. FUOD SERVICE: . . -. . _ . � ��- _---- --- -- - - -�� -- - --- -�- ---- - ---—-� ---- - _. ... � � LICENSE REQUIRED FEE PERMII'# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE �31T 0-IOOSEATS $85 _CONTINENTAL $35 I NON-PROFIT $30 �6�I . >100 SEATS $160 _COMMO�I VIC. $60 _WHOLESALE $80 — —KESID.KITCHEN $80 � RETAIL SERVICE: LICENSE REQUIRED FEE PERMI:# LICENSF,REQUIRED FEE PERMIT k LICENSE REQUtRED FEE PERMIT# <-50 sq.ft. $50 _>25,000 sq.ft. � $225 _VENDING-FOOD $25 ____ _FROZEN DESSER'f $40 _TOBACCO $95 _ _<25,000 sq.ft. $80 � � NAME CHANGE: $15 � AMOUNT DUE _ � �JO. OO •**•*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 4 ADMINISTRATION � , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license ar permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth 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 OCCUPANCI': For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temparary 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 ar 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 pnor to opening.PLEASE NOTE:People aze NOT allowed to srt m the pool area 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. FQOD SER�'?f'E 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 reqmred Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.varmouthma.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 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 COOKING: Outdoor cooking,preparation,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 RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2012. 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: 11/26/2012 SIGNATURE:�/�� y�-��0 ,A��I,,., , � -w,'K "i�� PRINT NAME& TITLE: Linda Zevi tas, / � Nutrition Proqram Manaqer Rev. 10/09/t2 � � . ^ Client#: 39689 ELDERSERVN � ACORD�, CERTIFICATE OF.LIABILITY INSURANCE ow��nuimorvrrr) t�rzsrzo�z THIS CER77FICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFlRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CER7IFICATE OF INSURANCE DOES NOT CONS7TfUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the ceR�wte holder is an ADDITIONAL INSURED,the policy(fes)must be endorsed.If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certiRcate dces not confer rights to the certficate holtler in lieu of such endorsemenl�s). . � rxooucErz . � �E^� Chris Hedetniemi HUB Intemational New England PHOME 508-945-0446 ^" 508-945A736 265 Orleans Road ac "°,E"`: '�,x°: EiIAIL North Chatham,MA 02650 A�R�S� . 508 945-0446 INSURER(S)NFFORDING GOVERl�GE Nac x wsurseaa:Hartford Casualty Ins Co INSURFD INSURER B: Elder Services Of Cape Cod& � u�sunErc c: The Islands Inc 68 Route 134 ixsurseno: 5 Dennis, MA 02660 INSURERE: INSURER F:. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD INDICATEO. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANV CONTRACTOR OTHER OOCUMEM WITH ftESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR PAAV PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AODLBIIBR POLICY EFF POLILV E%P LT2 iYPEOFINSURANCE INBR WVD POLICYNUMBER � MMIDO MMNO LINRS GENERAL LIpBILIrY � EACH OCCURRENCE E COMMERQAL GENERHL LIABILITY � DAMAGE TO RENTED PREMISES Ee ocwrrence $ CLAIMSMADE �OCCUR MEO EXP(My ane person) E PERSONqL8A0VINJURY $ GENEMLAGGREGHiE $ GENLAGGREGATELIMITAPPLIESPER PRODUCTS-COMP/OPAGG S POLICY PRO- L� § AUTOMOBILE LIABILITV � COMBWEO SINGLE LIMR - Ea acnEent ANYAUTO BODILYINJURY�Perperson) E ' �O NED A`C�HOESULED BO�ILYINJURY(Paraccitlent) $ HIREOAUTOS NON-OWNED PROPERTVDAMAGE AUTOS PerecvEent $ S ��e��wg OCCUR EACHOCCURRENCE E � E%CESSLIpB CLAIMS-MApE AGGREGATE E � DED REfENTIONE $ A won�ascorerexsnnox 6S60UB4727P36712 7/01/2012 07/01/201 Wcsrnru- on+ AND EMPLOYERS'LIAHILfTY ANV PROPRIETORIPARiNER/EXEGUTIVE y�� E.L.EACHqCQ�ENT $'I OOO OOO OFFICERIMEMBEREXCLU�ED? � N!A (Mantlerory In NH��. � E.L.DISEASE EA EMPLOVEE $�.00O OOO If yas,tlesaibe untler �ESCRIPrIONOFOPERATIONSbebw E.L.�ISEASE-POLICVLIMIT E��OOO�OOO OESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attac�ACORU 101,AtlElGonalltemarMa Schetlub,H more space u rtquiretl) CERTIFICATE HOIDER CANCElLAT10N � � SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE IXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN � ACCORDANCE WRH THE POLICY PROVISIONS. � AUTHORIZED REPRESENrATIVE ��.e�c e�-- m 1988-2070 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD � #5822804/M790429 CH004