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Home My WebLink AboutApplication and WC � . TOWN OF YARMOUTH BOARD OF FIEALTH ��" `� — ' �� APPLICATION FOR LICENSE 0�� ` " `. ��`��`�o�P � , ; * Please complete form and attach all necessa oc l�y,Dece ber Il Failure to do so will result in the return of your application p EPT. ESTABLISHMENT NAME• (��I<� alY, ��PD� �C`f� �1 L( TAX ID� � LOCATION ADDRESS: U+i Jt F� TEL.#: Sd8- G>2 -SG�� MAILING ADDRESS: v � -ZZY Z OWNER NAME: E L-S��' CORPORATION NAME(IF APPLICABLE): TAM�S - Z--��4 �-S-T�/C , MANAGER'S NAME: � tC'6 TEL.#: MAILINGADDRESS: v�l �r�n � � � `�� 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. I. 2• Pool operators must list a minimum of two employees currently certified in basic water safety, standard 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. POOD 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. 1. T'� 'V'�t N 2. � �t Y'�f�-! f.i! �S'IGn.+ PERSON IN CHARGE: Each food es[ablisYunent must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��c�brr.J 2. i'� � L� �p�'�vcvi 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 uained 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�le at your place of business. 1. Lc� (o`Ji,U 2. �A�( �r*YA:�{' 3. Gl,2rl�s (J� � 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 MOTEL $55 _lNN $55 _Cfu�4t� 5�5 _SW'IivtivlL\GF'J�i ao^vca. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $SOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $85 ��'✓�� _CONTTNENTAL $35 _NON-PROFIT $30 _>100SEATS $160 �COMMONVIC. $60 la�fl`f.� _WHOLESALE $80 __ RETAII,SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FHE PERMIT# LICENSE REQUIRED FEE PERMIT k _<50 sq.fc $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAA1E CHANGE: $15 AMOUNT D[JE _ $ I t-I�.`—j_U C �***°PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORA?***�* ADMINISTRATION � - Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewai 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 CONIPLETED AND SIG:�.'ED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED Town of Yarmouth ta�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO li3O�LS Al'v'B f3Tig�P.i3ODGING EST't1�d.IS`rI�i '�NT"3 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 demonsuate 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 priar to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People aze NOT allowed to sit in 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 certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLQSING: 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.yarmouth.ma.us under Health Dzpartment, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafrer,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: Outside cafes(i.e.,�iitdonr ce�tin¢with suaiter/F��ai:re�s ser.�icel,mnstha:�e p±ior apgroval fr�r:i the Board of Hea1Lh. OUTDOOR COOKING: 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 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUII2ED FEE(S) BY DECEMBER 15, 2011. AI,L RENOVATIONS TO ANY FOOD E3TABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENC ME T. RENOVATIONS MAY RE II2E A SITE P AN � DATE: SIGNATURE: 2� � PRINT NAME & TITLE: ,�� c��✓I I.A ts S � �--�-��=f Rev.10/?S/11 RightFax C1-2 12/2/2011 4 : 18: 42 AM PAGE 2/002 Fax Server ACORD. CERTIFlCATE OF LIABILITY INSURANCE ,voyzo„ 7HIS CERfIRCATE IS 19SUED�AS A AUITTER OF 11FORMA710N ONLY AND CONFERS NO RM,H18 UPON 7NE CER'TFICAlE HOLDER. 7HIS CEICIIFlCATE DOES NOT AFFIRAIA7IVELY OR NEOMIVELY AAAEND,EXTEND OR ALTER 7HE COVERAOE AFFORDED BY 7HE POLIpEB BELOW. T�SCER7IFICATE OF WSURANCE DOES NOT CONS'IiTUTE A CONfXACT BETWEEN7HE ISSUINO NSURER(8�AUMOPo2ED REPRESENTA7IVE OR PRODUCER,AND 7HE CE�i►IFICA7E HOLDER YVORTANf:M tM oMKot�holdv k s�ADDfilON11L NSURED,tM pdby(Ip)mwt M�ndonW. X SUBROOA710N IS WAIVED,su6�Mto d� Mms erN ea�lior d tM VabY.a�Min po6oiw mry rpuin sd�dawm�rf. A�febmM m W�ca6Bcab dae�at conts ri¢ts b IM aNfoeh holda h Ilw ot woh�ndwasmM(s). PRODUCER �p�(TAp'{ NAME: PHONE FAX BRYDEN&SUILIVAN INS (A�C,Ho,Ea): ppX �uc,No�: 88 FAIMOUIH ROAD e.wu� ADDRESS: PRODUCER HI'ANNIS,MA 02601 CUSTOYERIDt. ��S 9lSURER(S�AFiORDIN(iCOVERAOE NAICi INSURED INSURERA: ACEAII�RICANQYSl1RANCECdMPANY INSURER B: JAMES A LIADIS INC DBA HLACK SIIFEP BAH AND INSURER C: GRILLE INSURER D: . &4 ROCKY RIDGE ROAD �l13URER E: DENMS,MA O7b38 Il�URERF: COVERAOES CERTFICATENUAABER: REVISWNNWBER: T/9818 TO CERfIFY TFU1lHE VOUCIEB Of INBURMICE L18TE0 BELOW HAVE BEEN IBBUEO TO THE INBUREO N11ME0 ABOVE FOR TNE VOUCV PEPoOD INdC11TED. NOTWIfHHf4iDIN0 ANY REGURBA61f�TERM OR CONURION OF 11NY COMRACT OR OT1EP DOCIKIENT WRH pEeGECf TO W WCH TMB CERfIRCATE YAY BE 186UE0 OR M11Y iERf4M. THEINBUNANCE OFPoROED BV THE POLICIEB DEBCRIBEU MER�N IB BUBJECTTO�LLTHETERYe,EXCLU810N8 ANO CONDITIONS OF BUCH VOLIqEB. LIMHf881WWN WY II�VE BEEN REUUCED BY PMDCLAWe. 918R MCLBUBR GOIICY EFF DATE POIICY E]!V DATE TYVEOFINBURANCE VOLJGYNUAIBER (INi.001YYV7) (1AMOM1^IYY) LIppTB LTR MieR WYD OENERAIUA&LRV EACHOCCURRENCE $ COMMERCIAL OENERAL LIA8ILITV DAMAGE TO REN7ED s CUMS MADE OCCUR. PREMISES(Ea occurrence) MED EXP(My aw pereora S PERSONAL 88 ADV MJURY S GEML AOOREOATE LIMR APPLIES PER: GENERAL AG6RE6ATE s POLICV PROJECT LOC PRODUCTS-COMPlOPAGO S AUTOMOBILE LIABILI7Y COMBWED SN6LE S ANV AUTO LMIT(Ea acddaR) ALL WVNED AUTOS BODILV INJURV 3 SCHEDULEAUTOS � (p��) HIRED AUTOS BODILV INJURY s . (P�xcNeM) NON-OWNEOAUTOS PROPER7Y DRMAOE s (Per acddaU) U�.�BRELLALWB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMS-MADE A66REGATE $ DEDUCTIBLE $ RETENTION 3 g WCSTAMOftYl1MIT9 074ER WOPo(ER'S COYVENSATON ANO EMPLOYERS LIABIIJlY YM U&4495P756-11 0&062011 03,Ofl2012 E.L.EACH ACCIOENT S 500,�0 ANv PRaPEra7oRm�WTNF3vExEcunvE N E.L.DISEASE-EA EMPLOVEE S 500.000 OFFICER/MEMBER E%CLU�ED7 (MYrM�mryln IAp E.L.DISEASE�POUCV LIMIT S 500,000 II yae,tlncil0e in0er DESCRIPTON OF OPERAiIONS below DESCNIViWN OF OPERATIONS/LOCATION&VEHICIESIRESTRIC710NS/SPECUIL I7ENS TfIIS RPPIACES ANY PRIOR CIX7'(P[CA7E[SSUED TO THC CPRTIPICAIE HO[DFR MPBC7pdG WORI�iS COMP COVPRAOE. CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOU'[H SFpULD ANY OF7FiE ABOYE OESCPoBED VOLICIES BE CANCELLED BEFORE THE E1(PIRA710N DATE7HEREOF,N0710E WILL 8E DEWERED W �146 MAIN ST ACCORDANCE WRFi7HE POLICV FROVISIONS. AUfNORRED REPRESQ(rA7NE socrrx rnxMotmi,Ntn ou�a John J. I.apica ACORD 25(2009f0Y) 198&200Y ACORD CORPORAT�ON. 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