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Home My WebLink AboutApplication and WC . _ . B�ack ��i�P � TOWN OF YARMOUTH BOARD F $EALTH ` �� APPLICATION FOR LICENSE/P�T -2013 � � �-°• �� `�3�� ' � � * Please complete form and attach all necessary documents by Deqember I5. 2012. Failure to do so will result in the return of your application,packet. � �-•----:_�._.._._.'..�..'; . � ESTABLISHMENT NAME:�C�cIc �bte��a.lt�. l�i-h ( I TAX ID: � LOCATION ADDRESS: TEL.#: Z�o MAILING ADDRESS: o - > 0 � OWNER NAME: �t '- i�},�r CORPORATION NAME (IF APPLICABLE): J , Lz<t�L L,v , MANAGER'S NAME: ; C�C (.P l E' f1�er eP TEL.#: Svk�177 I .�`','l �Z MAILING ADDRESS: g� � !� � . � v r � Q.2G"7 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operat�r(s) and a.ttach 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). 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 are 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. �.��! T b�N _z. ste�6;��nP� i=ii��i�N iIv C�i�i�iiE: __ . _ _ _ — -__ _ __ _ _ Each food establisl�ment must have at least one T'erson In Charge (P1C) on site during hours of operation. � �. ��lTvb,N �. ��kC�� p�9��, 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. �� U�;,v 2. 7A�'L�,'S �(1-�(� 3._�' ,n i��P.t � 1 }_P_ f�cr- 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQOIRED FF,E PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&8 $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMING POOL $SOea. _LODGE $55 _TRAILER PARK $lOS WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-]00 SEATS $85 ��_ _CONTINENTAL $35 _NON-PROPIT $30 _>(00 SEATS $]60 I COMMON VIC. $60 ��_-p�o _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSB REQUIRED FEE PERMIT# _<SOsq.ft. $50 _>25,OOOsq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.fr. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $IS AMOUNT DUE _ $ � � 'rj ,OO *****PLEASE TURPi OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINI5TRATION I ' 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 t/ 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 Ali�D OTHER LODGING ESTABLISHMENT5 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 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 prior to opening. PLEASE NOTE: People are 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 wliform 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 o£ closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: A11 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 obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Doumloadable 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: Outsitle eafes-(i.e.,out�oorse�xig w�th waiter/wa�Yr�ss se�c-icel,must have prior approval from the Board of Hea1_tb. 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 TT 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 COMM�NCEMENT. RENOVATIONS MAY RE�UIRE A SITE L P�I. / DATE: ( �� I�� SIGNATURE: ,.-�' ' � PRINT NAME &TITLE:�� ;�� I fill�t e�S�'k � �`��'��-T ��'�`��N� � Rev. 10/09/12 -- - - - , .. . ----- . .. --�---- -- ---� !�� JAMES-2 OPID: DS '`�`�R� CERTIFICATE OF LIABILITY INSURANCE OATE�MMIDD/YwY� N/28N 2 CERTIFICATE DOES NOT AFFIRMATIVELY 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(S), AUTHORIZED REPRESENTATIVE OR P RODUCER,AN D THE CERTIFICATE HOLDER. IM ORTANT: the certi icate holder is an ADDI ION INSURED, the policy(ies)must e endorsed. If SUBROGATION IS I ED, su �ect to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does�ot confer rights to the certificate holderin lieu ofsuch endorsement s. Bryden&SullivanlnsAgency � PHONE FAx 86 Falmouth Road Fax: 508-790-141 ac rvo ea: �ac,rvo�: Hyan n is,MA 02601 E-MAIL Hyannis Office - wsuRerzn:Aspen Specialty Insurance INSURED JamesA.Liadis,Inc.DBA ir,suaeas:TheHartford 22357 64 Rocky Ridge Road ir,su�eRc: Dennis, MA 02638 INSURER D: INSURER E' INSURER F' THIS IS TO CERTIFY THAT THE POLICIES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME� ABOVE FOR THE POLICY PERIOD � CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCWSIONS AND CONOITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ir�sR LTR �E OF INSURANCE POLICY NUMBER MMI�D MMIODM'YY LIMITS GENERALLIFBILfiY EACHOCCUP,n^=NCE $ 'I�OOO,OO A X coimntiacaiceNEarta�unsiu� BZ924412 02/25/72 02/25/13 p�Enaisesi-aoo��e:,oe� 8 50,00 CLAIimS�vwDE �oCGUR mED EY3(My ora�erson) g 1�00 � �ERsona�aaflvw��R�� g 1,000,00 X LIQUOR/$iM/$1M ceiae�n_acce��nr_ s 2,000,00 ceN��neceecarumirnaaues�Gz aaooucrs-coMwoPncc s 1,OOQ00 Poucv PROr �oc Em Ben. $ EXCLUDE AUTOMOBILE LIABILITY 7 i u V-�c i u (Eaaccidentl $ ANYAUTO BODILYINJUP.Y(Perperson) 5 AUi05NED S�C�,�i�EDU_ED BODILYIWURY(Perawiden[) �5 HIREDA'JTO� NOIaOWNED ,�OPERTYDHNWGc AIITOS Pereocioenq § � UMBRELLALIAB OCCUR EACH OCCURRENCE 5 EXCESSLIAB CLAIMS-MHDE AGGR=GFTE $ DED RTIVrI $ WORKERS COMPENSATI AN EMPL VER 'LIA6ILRY Y�N TORY L MITS ER B bvFicEeim��zauoeovcume H�p OBWECCI6466 03/06112 03106113 e.�.encrinccioevr s 500,00 (MantlatoryinNH) EL.DISEASE-E4EMPLOYE: $ SOO�OO R yBS,tl¢$CnbB unOB� oescRivnoN oF oPeannoms oemw e.�.oisEa.se-aoucv um�r s 500 00 DESCRIPTION OF OPERqT10N5/LDCATIONS/VEHICLES (Attach ACOR�101,Atlditional Remarks Schetlule,if more spatt is requiretl) ear round restaurant with liquor YARMOI6 SHOULD ANY OF THE A80VE DESCRIBED POLICIES BE CANCELLED BEFORE YA R M O U T H TO W N HA LL ACCORDANCE WITH THE POLICY PROVISIONS. 1146 MAIN STREET qUT�{ORIZEDREPRESEMATiVE SOUTH YARMOUTH,MA 02664 Hyan�is Office I O 1986-2010 ACORD CORPOR4TION. 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