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Home My WebLink AboutApplication and WC ►r� ' ;- . $ 0. Ei-DqzSEeviCE$ - e. �� TOWN OF YARMOUTH BOARD OF HF�AL'CH Y�jRmo�T�+ tJvr2a�lc � APPLICATION FOR LICENSE/PERMIT�-2011 � S tTE �e ; * Please complete form and attach all necessary docum �nber 1 S� 10�' �'� ��"'/� Failure to do so will result in the retum of your application pac et. . �{7 1 , _.�.._ _ _ _ ESTABLISHMENTNAME: EIder Services of Cape Cod and the IslandsTtY3{cTD� LOCATIONADDRESS:�9R Fnract a� anua Yarpouth TEL #� MAILINGADDRESS: 68 RoUte 1 4 Snuth nonnic Ma n��Fn OWNERNAME: Elder Services of Cape Cod and the Islands Inc CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME: Gail MurraY (MOW) Chervl Grenier (Senior DiningjCEL # �ntt zou �n�n MAILING ADDRESS POOL CERTIFICATIONS: The pool supervisor must be certiGed as a Pool Operator, as required by State lativ. Please list the designated Pool Operator(s) and attach a copy of the certification to this forni. I. 2 Pool operators must list a mniimum of two employees cun•ently certified in basic�vater safety, staudard First Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintxin A 61e at your place of business. 1. 2 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments az-e 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 Establislunents, 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}�our establishment. 1. Cathy Hambleton- Site Supervisor 2.Linda Zevitas- Nutr•r; o — � ger PERSO_N 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site dur'vig hours of eperation. 1. Gail Murray- Meals on Wheels Z.G/Cheryl Grenier-Senior Dininq 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 tranied in'anti-chokmg procedures below aud attach copies of employee certifications to tlus form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L Gail Murray 2._ Cath 3. Lin a evitas Y Hambleton 4. RESTAURANT SEATING: TOTAL # Lonci�c: OFFICE USE ONLY LICENSE REQUIRED FEE PER'bIIT# LICENSE REQUIItED FEE PER\qIT#? _B&B S�_ C�� LICENSEREQUIRED FEE PER�IITz - -. .._I *A�* . . — S55 _D40TEL S55 -- ---`--SSw_ —..-_ _:._�A.'--�3--- - ----355------ LODGE �— - _ .. � � �t SSOea. - . - . — S55 _IRAILERPARK 5105 � . FOOD SER�7CE: .—.�;HI�-P�OL SSOea. LICENSE REQUIRED FEE PERbIII# LICENSE REQUIRED FEE PER'�fIT� LICENSE REQUIRED FEE PER�IIT t _0-100 SEATS S85 _,CONIlNENTAL S35 _>I00 SEA'IS SI60 - LNON-PROFII g;p �ll,��C�a _COYL'vION V(C S60 \�I-IOLESALE S80 RE7AII.SERV[CE: — LICENSE REQL7RED FEE PERYIIT u —�SID.KIiCHEN S80 LICENSEREQUIRED FEE PE&YIIT- _a50 sryft. S50 LICENSE REQUIRED FEE PERVIII'_ _>25.000 sq.R. 5225 VENDiNG-FOOD S25 _<25,OOOsq.ft. S80 _FROZENDESSERT S40 �A�4ECHA\GE: S15 _IOBACCO gjj AMOUNT DUE _ $ 30.00 "*•"'PLEASE iLR\OVER e1\D CO�IpLEiE 07HER SIDE OF FOR�I**•** y 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 AFFIDAVTT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED�_ OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: yES NO 1_VI4�'I''�L3 A.�l-13 4�1'f�Elt I.f.'IT£Y'L'!'U �:STrL�L,�3iI:Y1EN'f5 _ __ _:_ _. TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel 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 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 tlu�ee(3)days pnor to opening.PLEASE NOTE: People are NOT allowed to sit 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 Heahh Department three (3) days prior to opening, and quarterly thereafter. pppL CI,i].SiNG:Evec3r_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 inspectaon three(3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required 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 varmouth ma.us under Health Department,Dowcdoad'alile 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 Heakh Department. Failure to do so will result m the suspension or revocation of your Frozen Dessert Pemut until the above terms have been met. OUTSIDE CAFES: Outside cafes{i.e., outdoor se.ating with waiterh�vaitress servicel,must have prior anpr�val fromthe Board ofHealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � prqpLE E RENEWAL APPLICATION(S)eAND REQUIRBD EE(�B YDECEMBER lO5 O10� ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TIIE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � DATE: 11/30/2010 SIGNATURE: PRINTNAME&TITLE:Linda Zevitas, Nutrition Program Manager 10'0610 I � _ s �� _�_ ,. � � �..__.' .�.:: .. .. , .L��"�� ..... Client#:39689 ELDERSERVN ACORD,� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIWYY) os�so�so,o PROOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION HUB Intemational New England � . . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 265 Orleans Road HOLDER.THIS CERTIFICA7E DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Chatham,MA 02650 � - 508 945-0446 INSURERS AFFORDING COVERAGE NAIC# wsuaeo � irvsuRean: Travelers Property Casualty Co 25674 . Elder Services Of Cape Cod& INSURER B: AIG The Islands Inc irvsuaeac: Safety Insurance Co 68 Route 134 � - S Dennis,MA OYGBO � INSURER D: � - � INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER100 INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR � MAY PERTAIN,THE INSURANCE AFFOR�ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � $R POLICY EFFEGTIVE POLICY E%PIRA110N LTR NSR TYPEDFINSURANCE POLICYNUMBER TE MM/DO DATE MM/D� IIMITS � p GENERALLIABILITY 16609529N774 09/01/2010 09/01@ON EACHOCCURRENCE 5p COMMERCIAL GENEF2qL LIABILITV DAMAGE TO RENTED f CLAIMS MAOE ❑OCCtIR MED EXP(My ona pe�son) $ PERSONAL 8 AOV INJURY SO GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ POLICV PRO- JEGT LOC C AUTOMOBILELIABILITY 2703305 �7��2�� D7��Z�� COM6INE�SINGLELIMIT ANYAUTO (EaawtlenQ a ALL OWNED AUTOS BOOILYINJURY $��OOO�OOO SCHEOULEDAUTOS (Perperson) . X HIREDAUTOS BODILV INJURY 51,000,000 X NON-0WNEDAUTOS . (PCreccitlenQ PftOPERTVDAMAGE a500'o00 (PerecddenQ GAMGEWBILITY AUTOONLY-EAACCIDENT S ANYAUTO OTHERTHAN EAACC S AUTOONLY: qGG S E%CESS/UMBRELLpLIABILITY EACHOCCURRENCE $ OCCUR �CLAIMS MAOE pGGREGATE $ $ DEDUCTIBLE S RETENTION Y E B WORKERSCOMPENSATONAND WC003977510 Q7�Q��'jp�0 Q]�p��'ZQ�� WCSTATLL OTH- EMPIOYER3'LIABIt1TY � ApNY PROPREIEfORIPARTNERIEXECUTiVE E.L EACH ACCIDENT $�OO OOO (NenEatorylnM��RE%CLUDED'! � � E.L.DISEASE-EAEMPLOYEE E�OO�OOO If yes,tlesaibe uMer SPECIAL PftOVISIONS belax E.l.DISEASE-POLICY LIMIT $SOO OOO OTXER DESCRIPl�ON OF OPERATIONS/LOCATIONS/VEXICLES I E%CLUSIONS ADDEO BY EN W RSEMEfJr I SPECIAL PROVISIONS !b CERTIFICATE HOLDER CANCELLATION � SHOfILO ANV OF THE ABOVE DESCRIBED POLICIES BE CANGELLED BEFORE THE E%PIRATION � - DATE THEREOF,THE ISSUING INSURER WILL EN�EAVOR TO MAIL �_ pAY3 WRITTEN NOTICE TO THE GERTIFICATE HOlOER NAMED TO TNE LEFT,BUT FAILURE TO DO 50 SHALL IMPOSE NOOBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITSAGENTS OR REPRESENTATIVES. AU�RIZ�RESENTATIVE N rJ/ AY lM�� ACORD 25(2009101)� of 2 #S431841/M431839 0 1988-2009 ACORD CORPORATION. All rights reserved. 7he ACORD name and logo are registered marks of ACORD RT001