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Home My WebLink AboutApplication and WC -�`"` G��N�� a TOWN OF YARMOUTH BOARD OF HE TI�.� �t�, ' ' �� APPLICATION FOR LICENSE/P � � �� : �Q'( 0 � Z G 11 �.,. * Please complete form and attach all necessary u y ecem er 1 DEPT. Failure to do so will result in the return of your applicauon pac . ESTABLISHMENT NAME: �fIN ��c� G�/GCE� „��'�r��/�-rj',� ID: LOCATIONADDRESS: /2g7 /�-}�v Si Sour/� NA�/hau,-ii TEL.#: S6J� �5' -�z7 MAILING ADDRESS: / ,� ' .t� . .t' ae' ' / �" OWNER NAME: �4u c �c K,�,.. CORPORATION NAME�IF APPLIC�ABLE): MANAGER'S NAME: Ce/f /,S-C/N�o TEL.#/ 5�1�° S'3/r U 57/ MAILING ADDRESS: D- e.� � 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. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standazd 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�le at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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 establish ent. m°r �"� (� /� ,qr�vA � � L�I� �'�iG�,•�1� 1. JCeN A�i_-.2.a^A�� 2. ,Je_ fr�.rrh ,�� i��r.- PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. �G�� lLMKd 2. /�/�i> ��of1/f�- 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 tunes. 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. 2, 3. 4. RESTAURANT SEATING: TOTAL# �� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LiCEIVSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _M07'EL $55 _1NN �y55 _CAMP $55 _SWIMMINGPOOL $SOea. _IADGE $55 _TRAII,ERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-]OOSEATS $85 '��J _CONTINENTAL $35 _NON-PROFTT $30 _>I00 SEATS $160 � COMMON VIC. $60 � I Z'�.� _WHOLESALE $SO RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT R LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NnME cxnrrcE: gis AMOUNT DUE _ $ i� S .OU g�g$*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**••+ �..r- ADMIIVISTRATION " 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 1/� 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 MOTELS AND OTHER LODGING ESTABLISHNI�NTS 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 ninery(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 CNII2 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 ihe 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 m the pool azea until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarteriy 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 OPENIlVG: 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 obtamed at the Health Department,or from the Town's website at www.yarmouthma.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 Permit until the above terms have been met. OUTSIDE CAFES: - Qutsi�e eaf'es(:e.;otzt�ece seatir.g�xitkc�zi.�rfwsitress service),mUst h�ve grio:apgroval fre:n the Boazd of Health. OUTDOOR COOKING: Outdoor cooking,prepazation,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 RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUII2ED FEE(S)BY DECEMBER 15, 2011. Ai"T. RENOVATIONS TO ANY FOOD ESTABLISF�v1ENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MA�REQUIRE A S/I��7'F,�`�.A�d:J % � DATE: l l/ SIGNATURE: 7Q�2C /� , PRINT NAME &TI1'LE: P,4:�!4 l� �G%C�.,,.- s�%PJ�G�e� T � Rev.10/25/II ,acoRO� CERTIFICATE OF LIABILITY INSURANCE DATE�MhVDDIYYYY) � ii�s�zoii �THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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(5), AUTHORIZED �REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiTcate holder is an ADDITIONAI. INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may requi2 an endorsement. A sWtement on this certificate dces not confer rights to the � certificate holder in lieu of such endorsement(s). {PRODUCER NAMEACT Sh@LL']� MCNdll]� �� Insurance Agency� IRC. PHONE (508)$9�—a$55 F� No: (508)540-9255 �8- Main Street E-M^�� .sherry@cape.com ��idnf INSURER 5 AFFORDING COVERAGE NAIC p Falmouth MA 02541-0656 INSURERHMSA GZ'011 =iwsuaeo INSURER B I1MGlldSCl 423 90 iI,�J 55 Food Service IIIC. INSURERC: ��dba D'Angelo INSURERO: -3�41 Lakeshore Drive INSURERE: 2larstons Mills MA 02648 INSURERF: COYERAGES CERTIFICATE NUMBER:CL1111331793 REVISION NUMBER: -THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOPMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUR4NCE AFFORDED BY THE POLICIES �ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHONM MAY HAVE BEEN REDUCED 8Y PAID CLAIMS. INSR ADDLSUBR POLICVEFF POLICYEXP LTR n'PEOFINSURANGE POLICYNIIMBER MM/D /DONYYY LIMITS GENERA�LIABILITY EACH OCCURRENCE $ 1�000�000 - X COMMERCIAL GENERAL LIABILITV DAMA E TO RENTED PREMI ES Eaoccurrence S 300�000 A.'. CLAIMS-MADE � OCCUR PT6411U /1/2011 /1/2012 MEDEXP(Myoneperson) $ S�OOO " PERSONAI.B ADV INJURV $ 1�000�OOO ��y� GENERAL AGGREGATE $ 2�O00�000 ��t�'��,:.-GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ E�OOO�OOO :..:: PRO- ��i?r�X POLICY LOC $ Af�" �AUTOM09LELIABILITV COMBINEDSMGLELIMIT Ea accidaM ' ��, ANY AUTO BODILY INJURV(Per person) $ ALLOWNED SCHE�ULED Bp�I�VINJURV Peraccitlen� E AUTOS AUTO$ ( ) ��'�' � HIREDFUTOS NON-OWNED PROPERTVDAMAGE AUTOS Peraccitlarrt $ S � UMBRELLALIAB OCCUR EACHOCWRRENCE $ EXCE55 LIAB CLAIM$-MADE AGGREGATE $ DED RETENTION$ $ $ WORKERSCOMPENSATION N/CSTATU- OTH- ANDEMPLOVERS'LIABILITV Y�N ANV PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 5OO OOO � OFPICER/MEMBEREXCLUDED9 � N/A � (MantlaroryinNH) HWC220906 8/1/2011 8/1/2012 E.LDISEASE-EAEMPLOVE $ 500 000 I(yes,desaibeuntler E.L.DISEASE-POLICVLIMIT $ SOO O00 DESCRIPTION OF OPERATIONS below '�UE5CRIPTION OF OPERAT10N5/LOCATIONS/VEHICLES (AHxh ACORD 107,Additional Renarks Scheduk,if more apxe is requiretl) it�i:�.� 1297 Main Street �5i�''Yaxmouth, MA 02669 - :i . a� -CE.RTIFICATE HOLDER CANCELLATION ' � SHOULD ANY OF 7HE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE � THE EXPIRATION DATE 7HEREOF, NOTICE WILL BE DELIVERED IN . Town of Yarmouth ACCORDANCE WI7H THE POLICY PROVISIONS. Board of Health 1146 Main Street AUTHORIZEDREPRESENTATVE � Yarmouth, MA 02664 D MeCarthy/SMCNAL �� ACORD 25(2070/05) �O 7988-2010 ACORD CORPORATION. All rights reserved. .INS025�smoas�.oi The ACORD name and logo are registered marks of ACORD :c_::