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Home My WebLink AboutApplication and WC . TOWN OF YARMOUTHB4OQRD-OF HEALTH C�a�SExurc�Z APPLICAITON FOR LICENS�� RMIT-ZO10 ��d�� *Please co lete form and attach all neces�aT3'ao wnen�b Dece " � y ��4� 2ob�:;��9 Failure to do so wiIl result in the retum of your application p •q�� H uE��. NAMEOFESTABLISHMENT: Elder Services of Cape Cod and the Islan�,Z�fc. 508-394-4630 LOCATIONADDRESS: 52$ ores veneue, armou MAILING AADRESS: • OWNERNAME: FE or • CORPORATION NAME (IF APPLICABL ): MANAGER'SNAME: Karen Kelly (Senior Didinq) Gail Murrav (MOW) TEL. # 398-5060 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 tlris form. 1. Z. . Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Commuuity Cardiopulmonary 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 maintafn a file at your place of business. �. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protecrion 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 your establishment. 1•-- �ar�^ Kally Sita Ceerdin�.�er 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. Karen Kellv- Senior Din�ng 2. (;a,�i M,,,-ry_ rnAa�� on Idheels 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 ecrployees trained in anti-choking procedures below and attach copies of employee certificarions 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. _ Cathv Nambletnn_ N � ri ion Site�par�,;��•• 2, 3. 4. RESTAIJRA.NT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICk,TISE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIR6D FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 �SWLMMINGPOOL S80ea. _LODGE $55 _TRAILERPARK $105 WI3IRLPOOL $80ea. FOOD SERVICE: LICENSE REQUfRED FEE P�RMIT# LICENSE REQUIRED F£E PERMIT# LICENSE REQUIRED FEE PERMTI# _a100 SEATS $85 _CONTINENTAL $35 /NON-PROFIT $30 0��0 >I00 SEATS $160 _COMMON VIC. $60 _WHOLESAL� $80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE R£QUIILED FEE PERMIT# LICENSE REQUIl2ED FEE PERMI'1'# LiCENSE REQUIRED FEE PERMIT�i <SOsq.R. $50 _>25,OOOsq.ft. 5225 _VENDIDIG-FOOD $25 ... . _Q5,000 sq.ft. �80 _FROZEN DESSERT $40 _TOBACCO $55 NnME c$n[vcE: si s AMOUNT DUE = S 3 0-O o ...««pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM«...« ADNIINISTRATION � . . � . Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernrit to operate a business if a petson or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSU1tANCE . AFFIDAVTf MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACF�D Town of Yarmouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CI�CK APPROPRIATELY IF PAID: yES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe timitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal plaae ofresidence elsewhete. Transient occupancy shal! 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,wad'mg and whirlpools which have been ctosed for the season must be inspected by the Health Departmentpnor to opening. Contact the Health Departmem to schedule the inspection ti�e(3)days pnor to opening.PLEASE NOTE: People aze NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total colifoim and standard plate count by a 3tate certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in�round swimming pool must be drained or covered within seven(�d�ys of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departmart by filing th�e required Temporary Food Service Applicarion form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sem 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 searing with waiter/waitress service),must have prior approval from the Board ofHeakh. OUTDOOR COOKING: Outdoor cooking,preparatioq or display of any food product by a retail or food service estabGshmeirt is prolubited. NOTICE:Pemuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILTI7t TO RETURN Tf� COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISI�v1ENT, MOTF,L 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. 4 DATE: 11/23/2009 SIGNATURE:—�.� 9� PRINTNAME&TITLE:�inda Z,e �ra� Nutritinn vroaram_Manaqer 09l25/09 t elder services of Cape Cod and the Islands � � � October 27, 2009 2010 Boazd of Health Applications At the request of our Insurance Agent, a Certificate of Liability Insurance for Elder Services of Cape Cod and the Islands, Inc. will be sent directly by the Insurance Agent to the requesting Town. "I'hank you. �e�� Linda Zevi Nulrition Program Manager Elder Services of Cape Cod and the Islands, Inc. 508-394-4630 x 401 68 Route 134, South Dennis, MA 02660 ph: 508.394.4630 fx: 508.394.3712 www.escci.org access /service /advocacy Date: .12/17/2009 Time: 4:30 PM To: 9,1508-760-3472 Roqers 6 Gray Ins. Paqe: 001 � CUent#:9434 . ELDESER ACORD,. CERTIFICATE OF LIABILITY INSURANCE ;Z;;,�°""�'''� rnoouceq THIS CERTIFICATE IS ISSl1ED AS q MATTERAF INFORMATON Rogers 8 Gray Ins.So. Dennis ONLY AND CONFERS NO RIGHTS IIPON THE CERTffICATE � 434 Route 734 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTENb OR ALTER THE COVERAGE AFFORDED BV TH E POLICIES�BELOW. � P.O. Boc 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC�1t �Hsaneo msoaERa: Selective Insurance Co.oT S.C�. � Elder Services oT C.C.&Islends Inc 68 Route 134 insu�ae: WSURER C' S. Dennis, MA U2660-37f0 IflSURER O'. INSUf2ER E: �COVERAGES THE�POLICIESOFINSURANCEUSTED6ElOWHAVEBEENISSUEDTOTHEINSUREDNAA,tEDABOVEFORTiEPOLICYPERI DIND VJITHS� NDIN AMY RE�UIREMENT.TERM OR CONDf�ION OF ANY CONTRACT OR OTHFR DOCUMENT WITH RESPECT TO WHICH THIS CER IFICATE MAV BE ISSUED GR MAV PERTAIN,THE INS�JRANCE AFFORDED BV THE POLICIES DESCRIBFD HFREIN IS SUBJECT TO ALl THE TERMS,E%CLU ON��y��;{ POLIqES.FGGREGATE LIfd1T5 EHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. LTR. NS TYPEOFINBURANCE POLICYNUMBER P�CYEFFECTNE iDLICYEXPIRpT10N O.TE MMID OA E O/YY � LIMRS /� GENEIULLIAe1LRY S1976903 12/07/09 12/01A0 EACHOGCURRENGE S 1 OUO 0lIU � X con�cnERc�at cEnean�uasam °u'wc�T°a�"'Eo � 5100 U00 ClAIM5MN0E �pCCUR AAEDE%Pqnymeperson) $�SOOO. PERSONAL 3ADV INJVRY E'I,OOO DOO . c�NEaaiAeGREcaTp S3OO0000 GENLAGGFtEGATELMITAPPLIESPER: PRODUCTS-C�MPIOPAGG S3OO0000 POLICV PE�4 LOG AUT�MOBIIF LU191LITV � COMBMEO SINGI.E LIMR ANYAUIO (EaavitleMl S ALL OINNEO AUTOS BODILV iNJURV , SGHEOULEDAUTOS (Perpersw) s H REDAUTOS NOfi-0IMJEDAUT05 BWRVINJURV 5 (Par actltlenq PROPERrYCAMAGE S (Pe�actltlMl) GAqAGE LIABRITY AUTD ONLV�EA pGCIDEM $ ANY qlfr0 OTHERTHAN EAACC E AUTO ONLV: A� $ E%CESSNM6FELlAlIq91LITY E/1CHOCLURRENLE S OGGUR �QAIMSMADE AGGREGA�E g a DECUCT'�BLE 3 RETENTqN j S WORNERSCOMPENSATIONANO 'NCSTATLL OTH� EMPLOYERS'11A61LITY qNYFROPFIETOR'PARTNEGE%EQJrIVE ELEACHFCCIOENT g OFFiCE WMEMBER EXCLUDE09 If)rts,tlescri0�u�cPi ELOISEASE�EAGIdFLOYEE F SPECIAL PROVISIONS GHow EL OISEASE�POLiCV LIMIT § OTHER oESCRIPT1pN OF OVERI.TI�N51lOCATI�NSI VENICLES/E%CWSIONS AOOEO 9Y ENOORSEMENT/SPECIAL pROVISIONS CERTIFICATE HOLDER CANCELLATION SH W LO qNY OF TME ABOVE�ESCXBEO POLICIES�BE CRNCELLEO BEFOqE TNE E%PIqATION TownofYarmauth OATETMEqEOF,TNE65UWGINSUFEqYALLENOEAVORTOMALL _jfL ORYSWWTTEN Board oi Health N0710E TOTNE CERTffICATE NOIOER NpMEO TO TME LEFf,BUT FA0.URE TO GO SO SNALL 1146 Ma i n Street,Ra ute 28 IMPOSE NO OBLIGATION OR LIA6ILffY�F ANY KINO UPON TNE INSUREP,ITS AGENTS OR SouthYarmouth, MA02864 ffEPpESENT�TIVES. � AUTMORIZED qEPRESENTATIVE / . �ACORD PS(2001/OB)� of 2 #S476771M47669 DD 0 ACORD CORPORATION 1988