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Home My WebLink AboutApplication and WC 1 �_'.. ' TOWN OF YARMOUTH BOAR�OF��AL'�'H G - � � '�' �� APPLICATION FOR LICENSEB�.�Y�I"��0�� ..• ;..� ._,. � � � ` �'1 .: I %G10 * Please complete form and attach all necessary documents by Dece� er I S 2010. Failure to do so will result in the return of your applicaUon pa et.HEALI"H DEPL ESTABLISHMENT NAME:��N�o�Lo G/2/LL C/.� fAi✓O%-'�c He' TAX ID' LOCATIONADDRESS: �ynJ .!'� � ,2 o4c� TEL.# -39 -ZZ27 MAILINGADDRESS: 3y/ Ls7-�[G _('/fip�E !J/� /rI,¢ J7-oi!> �lji�/1 �Yl� D2,�v� OWNER NAME: �,�„r.� E c,r ,c � CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: SGa 1'} /��rnyiod TEL.#: SD,P- 3—o S'/[ MAILING ADDRESS: '� i?ia 5�4�-o wic� . /1'!<i POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pnol Operator(s) and attach a copy of the certification t� this forni. l. Z. Pool operators must list a minunum of two employees cunently certified in basic water safety, standard Fn•st Aid aud Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofempioyee certifications to tlus foim. The Health Department wili not use past years' records. You must provide new copies and maintain a �le at y�our 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 Sanitazy Code for Food Seivice 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. I. SG o{� f'k'N//4/J � �II/� f„G��(1 2. /�YaA/.� Y/7`J�l (Wj . PERSON IN CHARGE: Each food establistmient must have at least one Person In Charge (P1C) on site durntg hours of operatiou. I. �J (� �C.ri✓Ano 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 yom• employees trained 'ui anti-choknie procedures below azid attach copies of employee cei7ifications 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. .9�A- 2. 3. 4. RESTAURANT SEATING: TOTAL # %�P OFFICE USE ONLY LODGL\G: LICENSE REQUIltED FEE PER'vIIT# LICENSE REQUIRED FEE PER�fIT F LICENSE REQUIRED FEE PER'�IIr# . —B'�B S» _CABIN 555 _b10I'EL 555 _II�N S55 _CAi�IP S» _S��'LVLVIINGPOOL S80ea. _LODGE S55 _I'RAILERPARK 5105 _F41-IIRLPOOL S80ea. FOOD SER�'ICE: LICENSE REQUIRED FEE PER��II"# LICENSE REQUIRED FEE PER\1IT= LICENSE REQUIRED FEE PER�1ff� I 0-100 SEATS S85 �� OIO _CONI'INENI'AL S35 NON-PROFIT 530 _>100 SEArS S160 �C01�ibION VIC. S60 ��667 _�vj-IOLESALE S80 RET.1II.SER�'ICE: —RESID.KIiCAEN S80 LICENSE REQUIRED FEE PERbiII'# LICENSE REQUIRED FEE PER�IIZ# LICENSE REQUIRED FEE PER�fII'R _<50 sq.8. S50 _>2i,000 sq.ft. S22i �'ENDING-FOOD S25 _Q5,000 sq.ft. S80 _FROZEN DESSERT S40 TOBACCO S55 ��zE ct[.a�cE: sis ANIOUNT DUE _ $ I�-45 .0� � **'"*PLEASE TtiR\O�'ER ASD CO�IPLE'IE OTHER SIDE OF FOR�i""**� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. 1'HE ATTACHED STA1'E WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED v OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces 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 OCCUPANCI': For purposes ofthe limitations ofMotel 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 ofresidence 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 Departrnent to schedule the inspection three(3)days pnor to opening. PLEASE NOTE: People aze 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 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 inspect�on three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling 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 Towds website at www.vazmouth.ma.us under Health DepaRment,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: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval fromthe Boazd ofHealth. OUTDOOR COOHING: 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 RESPONSIBIIdTI'TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ IRE A SITE AN �DATE: �U�� SIGNATLIRE: �u�—�i/ � PRINT NAME&TITLE: �� K�h-- 10 06 10 10/19l2@10 16:58 508-540-9255 DFM IN9_1RpNCE PAGE 01102 'A�a�� CERTIFICATE C�F L(ABiLITY tNStIRANGE �'�"""'°°'�""' �� io/zs�zozo THtS GERTIflCATE IS ISSUEO AS A AA�44TTER OF INFORMATiQN ONI.Y RND CONFERS N6 RIGHTS UPpN 7HE CERTtK�ATE HOLDER. THI$ CERTIFfGAT� bOES NOT AfFIRMATIdELY�2 P�GATNELY AMEND� EKfEt� OR ALTER THE COVERAGE AFF(7RUE0 6Y THE PW.ICIES eELOw. 7HIS GERTiF�Cn� OF u�tsur�nHce o[�s waT cansrmrtE a coNtRaCT sETWEEM THE �SSumG in9u�tExts�, AUTHORIZEO REPRE3ENTATNE OR PR4UUC�R AND TNE CERTIFICATE HOLDER. ]MPORTANT, N the certificai0e hotder ls an ADCRIONAL INSURED,tl�e pdicy('�}must be entlorseq, if SUBR06ATION(S NtANED,sobJact to the lerms and canditions of the ppliGy,Cettain palicies may requfre an endorsemerR. A afatemeM on this eert�qte does npt COMpr Yig11t9 tD the ESRIflG2t6 holtl�'in lieu ef Su4h p�idqfSCf112 9. nrtOWCFJt � $ha�CCy AFeNslly A1PAd Xnauraace Ag6riCy, TGC. PM6� , (506)SRO-4555 F��.fsos)s4o.sus_ 668 Main Street p��' ,9bBI�S�CipB.COA aF�awcOAtEflJDAAOOS�68�.-.._.__..� � - ----- Falmouth MA 02541-0656 ,,, ��R�9 aswmir�cw��en�E xn�� ihsurteo ixsimean:I�.SA Q]COu irasure�ts:GuarB Tasuiagce Co L8J 55 Food Service Sac. i �. �"' dha D�Aagalo nrsuxErto: _... .. ..'-- 3@1 Aakeahore Dtfve . _ .__.. ._......_._. N75UI�R E: Masstons aaills ria 02648 ---- F. COVERAGES CERTIFICAT@NUMBER:�10101423544 RENSIONNUh�ER: THIS IS TO CERi1FY THAT THE POLICIES OF IN$lJRA1�E LISTEO BELpW HpVE B��N I$$UEP TO n'IE INSURBD WAM6C A@6VE FOR TME P6LICY PERIO6 INDICATE�. NO'TWRHSTANDM6 ANV REGNJIREMENT, TERM pR CpM1DfT�PI pF A�JY CON7RACT OR OFMER COCUMENT WI7}I RESPECi'FO WH1CH THIS CERTiPICA7E IAAY BE I$$UE�OR AfAV PEfYi'qIN, 1H@ INSURANCE RFFDRDEO BY THE POLICIES OESCRIBED!{EREIN 13 SUBJECT TO ALL THE TERMS, EXCW3i0NS�Np GON61TtONS OF SUCH pOLICIES CIMIT3 SHOWN MAY HAVE BEEN REDUCED BY PAiD C�aiMS. iNsa TTPIE OF Ifa9YNN10E ~y PdJCY NIWid9Et Poucr� roucr ocv � ,. .r'EN�aa�u^'��,Y � Fac++acwRaEncE s .1,000,000 ;� X cKdr.�rtcu�c,�[�t,u Lwealn PREf�d 6 ncrL -..._. 3 300.00 D yl CLAIMSAIADE Q OCCUR PT6S11II !1lzo;a /1/zn}Z ��(�� 4 5.00 PERspieLbAwltiqRl' $ 1�OOU�004 __ GfiJERAL AGGRE6ATE...•-_5-•`—S.0�0:0�0 O[N'6 A9{�EC��E I.IMMf.�PPltEb PER; PRODUCT9.COMFRW AGG S 2 e C00 r C DO 8 POIICV LOC S Al1TOMDBM1ELJ0.BILRY {'qy�plNW$lyp��(T $ (Ea seei0en!} 'ANY Wi 0 9W0.Y iNJlF7Y(Pr Versan) 5 ALL ONNEo AUTOS B�ILY M.IURV(px BodtlnAy 5 ' sc�oixwnuros aaor�mvwmuc� --- �� —�-�---�...._..--- - NIREDAIIN9 �PotlCd6efC $ nqN-0wr�o wfro5 S S tIl18PELULW9 OCbJR ... . __ _ fACHOCIXIIgfENCE 5 � __ _ E%C�5 tliB CLAIM3M11bE AGGREGATE t � . OEIXl�C119LE S rs�nnorv t g H� .W�RPCERSCOMPENSATI6N STA7U- 07H- ANO EMPLOYERS LIA&tRY �'7 N nrrv wmaaerowr+nrtTrv�xecurrvc E.L cnaincnoErrt E 500 000 . OFFlCER+McM6EP E1iaWE�7 � N!A � �tiunaamrymxn� aerc11536s Js/aaso !1/soss ��,� 5 5�010Q� tty9e�dnal6aunder El O�9Eh9E-POUCYLnrifT S Sp0 000 DE9CRIPTION OF OPEAATION$plYqv I I tlEBCRIM�ONOFOPERAT10H5llOCAT10N8lVEWC�S(4trochACQRG1H.iddWondlAmxksScheduiStlmor�s�aakraquk� &E: 1297 Maia Street B,YarmquGri, MA 026dA CERTIPICA HO�DER CANCELLATIpN (50 B)42 8-7 32 S SHOUL4 ANY OF TF�ABOVE pEgCR�ED POLACIES BE CqNCBLLEO BHFORE TF1F IXPIRATION GA'fE THEREOF, NOTICE WG.L HE DE(.I��D IN 'le7pfl a£ Yarmouth AGGORDANCEWII"XTMEPOLGYPROVISIWlS. SoaXd of 7�ealth 1146 Main Strent �+ors�o�Rews�rrve YarmouEh, MA 02664 �P � D AICCaxChy/SMCNAL �^�^`�"� ��-� ACORD x5(2C09l08j �t9aB-2d09 ACGR6 C4RPGRA7'I�N. AN nghh�rraerved. IWM9r.��m�aroi Tha ArJ1�lf1 nsme anrl irwrn aro�anln�eroA�n�Ne�e�T Af'ACI'f