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Home My WebLink AboutApplication and WC .. iJ�J+�.e� �irL:i:'1� C)ilr; tLry4�i. ��a � TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LI� �� L LI�[�� ` * Please complete form and attach all n�� ocu#nents b'y D cember 13 2013. Failure to do so will result in th� ret f i rn��y 8 dr app rcati packet. a ESTABLISHMENT NAME: s c � ,F.� r,` / TAX ID LOCATIONADDRESS: TEL.#: Y 3Gz {z�a MAILING ADDRESS: g c-i � / �nrn�� NLe. U2 G 3 i' E-MAILADDRESS: % '� c.-c��r � b(�I� S�ecp b� ,�o�.` OWNER NAME: T�e c A� Lr_�t p2.s CORPORATION NAME (IF APPLICABLE): SAMe r A < L.:��rc 2�rt MANAGER'S NAME: (;I�S W c-Ke�S«- TEL.#: SZ�F Z��s/�2 MAILINGADDRESS: G�( �rc„«-d J Uc.� �.r,Mu��mc . 0��7� 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, 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 of their 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 are required to have at least one full-time employee who is cer[ified 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. �l-CQJ�Z�,� ��MM rs 2 J-c 2�,� f'� c ��I'�ie� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. �z e,� !''l�G�r �a. l�c��'ct.in�c,�-,uc�N ;�� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.009(G)(3)(a). 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. 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. �a.,ties Liw��r 2. 3. ;�.L.< <✓cFl.<{- �� 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $SS CABIN $55 MOTEL $55 IIV1V $55 CAMP $55 SWIMMINGPOOL $80ea. _[.ODG� $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 L;"14�-Cl t CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $160 �COMMON VIC. $60 � �-l±' y _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.R. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 —TOBACCO $95 � NAME CHANGE: $IS AMOUNT DUE _ $ j 4`�.GC_ *****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 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 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 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 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 Deparhnent to schedule the inspection three (3) days prior to opening.PLEASE NOTE: People are NOT allowed to srt in 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. 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 Department by filing 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, 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 Pertnit 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 Boazd of Health. OUTDOOR COOHING: 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 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLE'I'ED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 13, 2013. 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 REQUT A SITE PLAN. DATE: I�(a1�� SIGNATURE: � � PRINT NAME &TITLE: J�� ' �1�-��-f �N� Rev. 10/O8/13 y ... �r. ,.v.., a....,,, ,�u.,.� u�... ..uaaa.u.. vv.�.�u ....ravu� •..iw..., a.b ..'.., a. l /� JAMES-2 OP ID: DS '4`�� CERTIFICATE OF LIABILITY INSURANCE DATE�MMIOD/YYYY) 71127113 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMA7IVELY 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(5), AUTHORREO REPRESENTATIVE OR PROOUCER,AND THE GERTIFICATE MOLDER. IMPORTANT: If[he certificate holder is an ADDlTIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, su6jecl to the terms and conditions of the policy, certain policies may require an endorsement. A stalement on this ceRificate does not confer righls to the certiFicate halder in lieu of such endorsement s. PRODVCER CDNTACT Phone:508-775-6060 �E: Brydan 8 Sullivan Ins Agency pXONE F� 88 Falmouth Road Fax:508-790-14'14 ac uo [:i: ac uo: Hyannis, MA 02607 aooaess: Flyannis O�ce INSURER 5 AFFORUING COVERAGE NNC k INSURERA:TIIB I'I3PITOfCI 22357 INSURED James A. Liadis,Inc. OBA INSURERB:WESIEIfI WO�Id Black Sheep Bah&Grille wsurceac:Mount Vernon Fire Ins Co 84 Rocky Ridge Road Denni s, MA 02638 ie+surs�a o: INSIIRER E: INSURER F: COVERAGES CERTIFICATENUMBER: REVISIDNNUMBER: THIS IS 70 CERTIFY THA7 THE POLICIES OF INSUftANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POLICY PERIOD INDICATEO. NOTWITIiSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOGUMENT WITH RESPEGT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU6JECT TO ALL THE TERMS, EXGLUSIONS ANU CONDITIONS OF SVCH POLICIES.LIMITS SHOWN MAY MAVE BEEN REDUCED BY PAI�CL41MS. � ��T0. T1'PE OF INSUqANCE �DL SUB pOLICV NIIMBER MM�DpY EFF PO/DpV E%P ��MRS GENERqLUABILRY FACHOCCURRENCE E ��OOO�OO B X COMMERCIALGENERALLINBILIN NPP1349'I08 OY/ISI�9 O2I2511Q pR MISES Eaoccvrc�ence 5 SO�OO CLAIMSMADE O OCCUR MEO EXP M ane person $ �r��4 PERSONALBADVINJUftY 3 �r44��0�� GENERA�AGGREGATE S Z�ODO�000 GEN'LwGGREGATELIMITPPPLIESPER I PROOVCTS-COMPIOPAGG $ ��OOO�OO X POUCV PR� LOG $ AUTOMOBILE LUIBILITY COMBINEO SINGLE LIMIT IEa accident �ANY AVTO BO�ILY INJURY(Per pa�son) S AILOWNED SCHEOULEO BO�ILVINJURY�Para¢iEenl) S AUTOS AVTOS HIREDAUI'OS �N-OWNEO PROPERTYDAMAGE q All70S Peremident f UMHRELLALIAB OCGVR EACHOCWRRENCE f E%CE55 WB CLAIMS�M4pE HG6REGATE 5 DED R TENTION f $ WDRKERSCOMPENSATION WCSTATU- OT14 AND EMPLOYERS'LIABIIJTY RY LIMITS A ANYPROPRIETOR/PARTkER/E%ECUTNE y�N 08WECCI6466 03/OBIt3 03/08/�4 E.LFAGHPGCIDENT S 5�0�0� OFFICER/MEMBFR EXCLUDED? � N�A (Mantlatory in NH) E.L.�ISEASE�EA EMPLOYEE 5 SOO�OO I/yes.Eesuibe untle� DESCRIPTION OF OPERATIONS beiow �E.l.OISEASE�POLICY LIMIT 5 SOO�OO C Liquor Liability CL2636971 02/25/13 02/25N4 i I ' '`_ �� OEiCRIiT10N OF OPEFATIONS/LOCATIONS!VEHICLES �MoeM1 ACOR�t01,qOElllon�l R�meeka Sehedub�Ifmon�paw Is requirotl) ��v Restavrant C Liquor LisHility Limits— S1000K Per Person ,:_!1 iU �0�3 $1000X Per Accident $2000R Aggxegate HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION YARM003 ShiOULD ANY OF THE ABOVE UESCRIBED POLILIES BE CANCELLEU BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILI BE DELIVERED IN YARMOUTh1 TOWN HALL ACCORDANCE WITH THE POLICY PROYISIONS. 1146 MAIN ST S.VARMOUTH, MA 02664 AVTNORRED REPRESENTATIVE Hyannis Office O'1968-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks ot ACORD