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Home My WebLink AboutApplication and WC _ _�+c11r'��.: , ;�-) . , l,v � ��V 1��4'i' ._ � TOWN OF YARMOUTH BOARD OF HEALTH c�b�� APPLICATION FOR LICENS� `� 1�� b:. f i �U13 \�" * Please complete form and attach all necess�e ts,b�D ee l3. � Failure to do so wiil result in the retum of�ourapplicafi ESTABLISHMENT NAME: TAX ID: � `� LOCATION ADDRESS: TEL.#: � � MAILING ADDRESS: t E-MAIL ADDRESS: OWNER NAME:K�hD "C��Cl P . 1[�n 1 r� CORPORATION NAME (IF APPLICABLE): , MANAGER'S NAME: ! ` TEL.#: � 9 MAILING ADDRESS � OL CERTIFICATIONS: "/ The upervisor must be certitied as a Pool Operator,as required by State law. Pleas ' e designated Pool Operator(s ttach a copy of the certification to this form. �-� 1. 2• Pool operators must list a minimum of t loyees c y certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation( aving one certified employee on premises at all times. Please list the employees below and attach copies o r certi ic � s to this form. The Health Department will not use past years' records. You must prov' ew copies and mainta 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 at[ach 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. �'i o ��ta�C. a. �c�a r��c� �'�k-r�C�.�lc,� 3� �c�c� C;��v�Z y• �o� ��, �� cv�c�r�� PERSON ARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �, . 1. o'' , 2. �l C � �Q Y�l��i C�� Q. ALLERGENCERTIFICATIONS: � �`�� M�l�� \ All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the S`tate Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to tk�is application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �`s'� ��d \7 � �C�G�- 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department wili not use past years' records. You must provide new copies and maintain a file at your place of business. 1.��5�'�"1� M2(1C��C. 2. ' • 3. f'2 OfVC� i � l4_ 4. � RESTAURANT SEATING: TOTAL # �J`�' s' �54 `�bQ�C�C��- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 —TNN $55 CAMP $55 SWIMMING POOL $80ea LODGE $55 TRAILER PA.RK $105 _. WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-I00 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>I00 SEATS $160 T J� �COMMON VIC. $60 � `�-��,�-� _WHOLESALE $SO —RESID.KITCHEN $80 RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >2i,000 sq.ft. $225 VENDING-FOOD $25 =<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 NAME CftANGE: $15 AMOUNT DUE _ $ .-`��'''�'�' **•**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 renew�l 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 sha11 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 dweliing 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 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 Permit untii the above terms have been met. OUTSIDE CAFES: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval £rom the Board of Health. 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 I5 YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 13, 2Q13, — - ALL RENOVATIONS TO ANY FOOD ESTABLISHMF,NT, 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: ,�j SIGNATURE: ��//Gf'i�� PRINT NAME & TITLE:��(�( ��d��j�� d ��,� Rev. 10/OS/13 From:Debbie Kleponis FaxID:781-444-0090 Rodman Date: ll/27/2013 12 :56 PM Page: 2 of 2 �-�� ACAPW9 OPID: DK '`�`�R�� CERTIFICATE OF LIABILITY INSURANCE °"�`""'°°"""Y' 11127/2013 THIS CER7IFICATE IS ISSUED AS A MATTER OF INFORMAIION ONLY AND CONFERS NO RIGHTS UPON THE CERTIPICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAi1VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOROED BY THE POLICIES BELOW. THI3 GERTIFICATE OF INSURANCE DOES NOT CON3TITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SJ, AUTHORIZED REPRE3ENTATNE OR PRODUCER,AND THE CERTFICATE HOLDER. IMPORTANT: IT fhe certiflcate holtler Is an ADDITIONAL INSURED,the policy(les)must 6e endorsed. If SUBROGATION IS WPJVED,subJect to the terms and condltlans of the pdiey,certaln policles may requlre an endorsemant. A statement on thls certlflcate does not eonfer rlghts to the certiflcata holder in Iieu of such andorsement s. PRoo�R . Phone:781-247-7800 NMAE: Rodman Insuranca Agency,lnc. Fax:781-044-0090 °HD� 145 Rosemary St.,&dg.A C No E : AIC No: Needham,MA 02494-3238 EJdAIL Evan Tobasky nroa�ss: NSURHI�SJAFFOROINGCOYHiAGE NRIC� ineu�xn:Public Service Mutual NBURED LaPlaya dba Acapulcos INSUtERB: West Yarmouth Location 705 W 7th Ave Suite A3 INeURERC: Spokane,WA 99204 inaur�Ro: INSLRERE: INSUiER F: COVERAGES CERTIFICATENUMBER: REVISIONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURPNCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABWE FOR THE POLICY PERIOD INDICATED. NO7WITHSTPNDING ANY REQUIREMENT, TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 8Y THE POLICIES DESCRIBED HEREM IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CW�lDITIONS OF SUCH POLICIES.LIMRS SHOWN MAY HAVE BEEN REDUCED BY PAfD CLAIMS. TYPEDFINSURFNCE pOUCVNUMBER MNIpO MM1D �M� GENERALLIIIBRRY EACHOCCURRENCE $ �OO�OO A X COMMFRpA1GENERALLIPBILIIY P01D972 D6H812013 �6/�$/20�4 pREMISES Eaoccurrence S ��Or�� CLNMSMPDE �OCGl1R MEDE%P(Anyaneperson) Y S�OO PERSONAL&ADVIN,0.IRY E ��OOO�OO X LlquorLiabilily GFNERALAGGREGATE S Y�OOO�OO GEN'LA�GREGATELIMITAPPI.IESPER: PRODUCTS-COMPlOPAGG $ ��OOO�OO POLICY P LOG $ AUfOMOBILE LU&LRY COMB NED S NGLE IIMIT Eaacidem S A�.A�O BODILYINJURY�Perperson) S ALLOWNED Sq1EDULED �DI�YINJURY�PerecciGen[) S AUTOS NOrlOWNED P 0 Y /MF s HIRmAUT05 AUTOS Perecci0en[ S X UMBRELULIII9 X OCCUR EACHOCCURRQJCE $ ��OOO�OO A EXCE33W1B ��NMSMADE UMO'IIIEIH O6M8l2D73 OGHHIIO'IA q6GREGATE E ��ODO�OO DED X RETEMIONS I WOfd(ER8COMPENSATON x WC TA U- 0 - AM FMPLOYERS'LUBILITY ' A1 ANYPROPRIEfORiPARiNERID(ECUTVEY❑ NIA C03324673 08M5/2073 OSNSR01b E.LEACHACCIDENT $ 500�0� o�iceam�meQi Ewcwoem (MentleleryNNi) EL.DISEASE-EAEMPLOVEE S SOO�OO IFyes.tlescriGeunder DESCRIPTIONOFOPERATIONSbelovr ELDISEASE.PoLICVLIMR S SOO�OO DE9CRIP'fION OF OPHtNiIONB 1 LOCATON8IYEHCLE9 (ACaeh ACOPD 101,Adatlontl Wmark�SC��tluU,llmen�pa�I�rpWnQ : 416 Main St Route 28 West Yarmouth MA 02673 CERTiFICATE HOLDER CANCELLATION SAMPLE- SNOULD ANY OF THE ABOVE DESCRIBm POLICIES BE CANCELLED BEFORE �"""""'SAMPLE"""""""" 1ME EXP�tA710N DATE THEREOF, NOTICE WLL BE DELNERED IN ACCORDANCE WI7H TiE POLICY PROVISION& nur�wwzneo rserrseserrtnrne l�� O 1988-2070 ACORD CORPORATION. All rights reserved. ACORD 25(2010I05) The ACORD name erd logo ere regiatered merks of ACORD From:Debbie Kleponis FaxID:781-444-0090 Rodman Date: ll/27/2013 12:56 PM Page: 1 of 2 e_. {�� Rodman Insurance Agency, Inc. ]�"� 145 Rosemary St., #A Phone: (78'1) 247-78'ID � 1 '� Needham, MA 02494 Fax: (781)444-0090 www.rodmanins.com From: Debbie Kleponis To: Gilberto Pages: 2 Fax: (508) 418-5062 Date: 11/27201312:55:58 PM Phone: ( ) - Subject: Certificate Message: Attached.