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Home My WebLink AboutApplication and WC E�D�tt-SVGS — yka. Nu-rRt7�1oN � a TOWN OF YARMOUTH BOARD OF HEALTH s�� APPLICATION FOR LICENSE/PE � -�2012 q ~ * Please complete form and attach all necessary��um�nts by ece�m er��fl��b��D Failure to do so will result in the return o rybur applicauon pac et. �3,�1�V 2 ESTABLISHMENT NAME: � . LOCATIONADDRESS: 528 forest Avenue, Varmouth, Ma. TEL.#:508- - MAII.INGADDRESS: ou e , ou enms, a. 0 0 OWNERNAME: Elder Services of Caoe Cod and the Island� Inr CORPORATION NAME(IF APPLICABLE): MANAGER'SNAME: C il M1�urrdy., Yirmnirth Cita ('nnrdinatnr TEL.#: qqR_FnFn 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. 2• Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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. 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 file at your establishment. 1. Gail Murrav Site Coordinator 2, Cathy Hambleton Site S�pPrvicnr ' PERSON IN��_- _ _ _ _ . ___ __ ___ _-- ---- ---- - Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 1. Gail Nurray, Meals on Wheels Coordinator 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 anu-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. • 2. 3. • 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY , LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# CABIN $55 _,MOTEL $55 B&B $55 — � �. _CAMP $55 _SWIMMINGPOOL $80ea ,. —�N $55 _WHIRLPOOL $80ea LODGE $55 _TRAIT-ERPARR $105 '� FOOD SERVICE: LICENSE REQU[RED FEE PERMIT# LICENSE REQUIItED FEE PERMTT# LICENSE REQUIItED FEE PERMIT# _CONTINBNTAI- $35 L.NON-PROF[T $30 ��=6� _0-100 SEATS $85 _�� $80 >100 SEATS $160 _COMMON VIC. $� — —RESID.KITCFIEN $80 RETAIL SERVICEc LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICVENDING FOOD$25 PE� '. <50 sq.ft. $50 _>25,000 sq.fr. $225 — _TOBACCO $95 G25,000 sq.ft. $80 —FROZEN DESSERT $4� ,`�jO OC� — AMOUNT DUE _ $ NAME CAANGE: $15 #*tz* �•k**PLEASE TURN OVER AN�COMPLETE OTHER SIDE OF FORM �— ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or 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 CONIP. AFFIDAVTI' SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI.EASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OT�IER LO��T_rI(:ESTaBLI3HIl�NTS TRANSIENT OCCUPANCY: For purposes of the 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 shall not be considered uansient. 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 OPENIlVG: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.PL.EASE NOTE: People aze NOT allowed to sit m 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 certif"ied lab, and submitted to the Health Deparunent 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 DeparUnent 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 requued 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.vannouth.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: Gursia'e cxI'e�(i•e;�i��seatiug wi-�h waiter/wai�er se:v:cej,.nust ha-rapricr a�prci�a��rom t�$o�zi of Heair_h. OUTDOOR COOKING: 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 RESPONSIBILIT'I'TO RETURN THE COMPLE'I'ED REI•IEW,AI„AppLICATION(S)AND REQUg2ED FEE(S)BY DECEMBER 15, 2011. AI-l. RENOVATIONS TO ANy FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND AppROVED BY THE BpARD pp I��,TH PRIOR TO COMA�NCEMENT, RENOVATIONS MAy REQ[]II�E A SITE PLAN, DATE: 11/14/2011 SIGNATURE• -� `�ti�� r��j- ��L�n PRINTNAME& TITI,E: Linda Z24itas, Nutrition Pro �am Mana er Rev.1 d25/1] ' ' Client#: 39689 � ELDERSERVN ACORD,� CERTIFICATE OF LIABILITY INSURANCE DATE(MMNDIYYYI� � 10l31@011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(3),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holdar is an ADDRIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and condilions of the policy,certain policies may require an endorsement A statement on fhls cert�eate dces not wnfer righls to the certificate holder in lieu of sueh endorsement(s�. rnooucEa NpyEp T patricla Sanzo HUB Intemational New England P�N��:$QS-9�S-0M�s � N,: 508A45-0136 265 Orleans Road e.rea� Nor[h Chatham,MA 02650 ��s' 508945-0446 INSURER�S)AFFOROINGCOVFRAGE xucs wsursm n:Hartford Casualty Ins Co INSURED INBURER 8: Elder Servfces Of Cape Cod& The Islands Inc a+surs�xc: 68 Route 734 �+su�eo: S Dennis, MA 02660 NSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: � RE1/ISION NUMBER: THIS IS TO CERTIFV THAT THE POl1CiES OF INSURANCE LIS7EO BELOW HAVEBEENISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD INDICATED. NOTWITHSTANDING ANV REQUIREMENT, TERPA OR CONDITICNOF ANY CON7RACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 7HE TERMS, EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �I RR ��x�E pDOL lIB POLICYEFF POLICYE%P M13R WVD P�LICYNUMBER MM1D0 MMIpD ��W� GENERRL LIRBILT' EACH OCCURRENCE S CqMMERCULLGENERALLIqBILITY M E RENTED EMI E Ee o¢urtence S CLAIMS-MADE ❑OCCUR MED IXP(My ona pa�son) $ PERSONALBq�VIWURV E GENERALAGGREGAiE E GENLAGGREGAiELIMITHPPLIESPER: PRODUCTS-COMP/OPAGG E POLICY P CT LOC E A11TpMp&LE LU1g��JTy COMBINEO SINGLE LIMR Ee aaitleM ANYAUTO BODILYINJURY(PerpersonJ $ N.ULT�EO �TOS��O BODILV INJURY(Perecvtlmt) S NON-0WNED PROPERTYDAMAGE HIREDAlJr05 q�OS Paracdtlen[ $ S UMBRELLp LV1B p�UR EpCH OCCURRENCE S E%�Esa WB CWMSMADE A6GREGATE E DED RETENTION E § A WORKERSCOMPEN8ATION 6S60UB4727P36771 7/01/2011 07/01/201 WCSTATU- X on+ I1ND EMPLOYERS'LIABILRY ANY PROPRIEfOR/PARTNEfLEXECUTIVE��N E.L EACH ACCI�ENi E� OOO OOO OFFICERIMEMBEREXCLUDED? � N/A (Mentlafary 1n NH) E.L.DISEASE-FA EMPLOYEE $� OOO OOO OESCRUIP�TIONO OPERATIONSbelow E.L.DISEASE-POLICYLIMIT $� OOO�OOO OESCPoPTION OF OPERATIONS/LOCRilON3/VEHICLES(Attach ACORD 101,Mtlitianal Rema'ks SchedWa,M nwre apace k�equ4etl) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLJCIES BE CANCELLED BEFORE THE IXPIRATION DAlE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISION3. AUTXIXtIZED REPFtESFNTATIVE �� 1988-2070 ACORD CORPORATION.All rights reserved. ACORD 25(2010/OS) � p{� The pCORD name and logo are registered marks of ACORD #610703 � PS005