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Home My WebLink AboutApplication and WC �@ � TOWN OF YARMOUTH BOARD OF HE,ALTH p�� APPLICATION FOR LICENSE/PE�1VI�'G=2 1 ��8 _ .. � � ,..: : � . . * Please complete form and attach all necessary.:r}bcut�ients`by Dece ber Failure to do so will result in the return of your application p "``�T. ESTABLISHMENT NAME: '� TAX ID� � LOCATION ADDRESS: �� '. TEL.#: - � MAILING ADDRESS: OWNER NAME: CORPORATION NAME (IF APPLICABLE): Cl�- MANAGER'S NAME: j � i� TEL.#:`� ' � (p- �'� MAILING ADDRESS: � S � � a P CERTIFICATIONS: The pool su�p��isor must be certified as a Pool Operator,as required by State . Please list the designated Pool Operator(s) and attaeli,� copy of tbe certification to this form. �" ----�.. � v _. . .... 1. ,.. .. _.._. �` Pool operators must list a minimum of two e ees ently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resu ' ation (CPR). P e ist these employees below and attach copies of employee certifications to this fo . he Health Department w� t use past years' records. You must provide new copies and ma' m a file at your place of business. ., 1. 2. 3. /� 4. �' FOOD PROTECTION MANAGF,RS - CERTIFICATIONS: All food service establislunents 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 appiication. The Health Department will not use past y�ears' records. You must provide new copies and maintain a file at your establishment. 1. �(J�i��\�(�L l��La�.?, 2. ��'�` �CCG �,'�(Zv`lo `C.Cit(:ti �'`'''� ��,�,`�2-- �c.'�e t�,' � �L�s �r: ��r�..c._: , a Each food establishment must have at least one Person In Charge (PIC) on site during hours o£operation. i.d�c��i� N'�zsr�.�a�a1c�. a. C�,=� ��=1� N\��:k� 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. Kl(�-�'tQ�f\r�ii_, �QX1E�l��L� 2. ��+�''1� �'�J��t';�� 3. ��C, C' r` \la.;—��C (C+`�li 4. -y;` �"1�` � , , �Gl-�-� 4�C,�C��r� RESTAURANTSEATING: TOTAL# L c.�t;��i v��c�>-trt�,l>�-2�- OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 _MOTEL $55 _INN $55 CAMP $55 _SWIMMING POOL $80ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $SOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# __0-100SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $160 �1,3"65� I COMMON VIC. $60 1r I �`f7� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 V ENDING-FOOD $25 Q5,000 sq.ft. $80 _FROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 22� •00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***'* 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 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 CO}VIPEN5ATION 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 HoYel 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 coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days priar 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 Deparhnent by filing the required Temporary Food Service Application form 72 hours priar to the catered event. These forxns can be obtained at the Health Department,or from the Town's website at www.xarmouth.ma.us under Health Department, Downloadabie 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: n�l}C�,�P=?f�.�,,�ating�uitt�waiter/waitressservice�,musthav�}�rioTagpr9val_fi'om the�oard of Health. 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 31. IT 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 COMMENCE ENT. RENOVATIONS MAY REQ A SITE PLAN. �DATE: � �SIGNATURE: `'�-' �( PRINT NAME & TITLE: i- � i � Rev. 10/09/12 11/28/2012 16:47 7814440090 RODMAN INSURANCE AG PAGE 91/01 �� OP Ip: DK '`��R'� CERTIFICATE OF LIABfLITY INSURANCE °"';;,"812""' THfS CER7IFICATE IS 138UE0 AS A MATTER OF INFORMATION ONLY AND CONFEft$ NO F21GMT5 UPON TNE CERTIFICATE NOLOER.THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY T}iE POLICIE3 SELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CON3TfTUTE A CONTRACT BE7WEEN THE ISSl11NG IN3URER(31� AUTHORIZEI) REPRESENTATIVE OR PRODUCER,ANO THE GERTIFICATE HOLOER. IMPOR7ANT: 1 the certlfieate Nolder is an AODITIONAL INSURED,!he polieYlies)musL 4e andGrsed. If 3116ROGAiION IS WAIVEU,Su6�ect to She terms and condltions of the pollcy, ceRaln polleias may require an endorsement A splement on tlrs eeR�caie doe5 not cOMor rights to We cartiTioata holder In lieu of such endorsemant s- %tCDOCER g TS'I-P47-ISOD N4ME� taSRuaemarySt Bldgnq,lnc. 781�44-0090_�NO�uE,,�n` .- - _. _�°uc.na: . ,_. _. Needham,MA DZ4943z38 AnoRE9A _ ._._ . EvanTohasky °R°��R ACAPUI9 cuszRME.6��.K;—.— — — — — iwsuae�_�wrtrnpo covew+o�_. ._ n�ie r ixsuneo �aPlaya d6a Acapuleos �xsuaea�;Public Servica MuWal ___ .. � West Yarmouth LocaGon msvaei e: 705 W 7th Ave Suite A� INSURf•R C: 5pokane,WA 99T04 —' — —'— — — — ixsurs�eo: . — —„—, —, — — '— wsuaEn e: . — — .— —.. — — INSVRER F• — COVERAGES CERTIFICASENUMBER: REVISIONMUMBEIt: TMIS IS TO CERTIFY THqT 7HE POLtCIES Of IN5URANCE LISTEO BELOW HAVE 9EEN 135UED TO THE INSURE� NAMEO ABOVE FOR TME POtICY PERIO� INDfCATEO. N07W17HS7ANDING ANV REQUIREMENT, TERM OR CONOIT�ON OF ANV CONTRACT OR 07HER DOCUMENT WITH RESPECT TO WHICH iH15 CERTIFlCATE MAY flE ISSUE� OR hL4Y PERTAIN, THE INSURANCE AFFOROED BY THE POUGES DESCRIBED HEREIN IS SUB3ECT TO ALL T1iE ?ERMS, F]CCLUSIOiJS ANO CONDITIONS OF SUCH POLIC�ES.LIMITS SNO�NN MAY HAVE BEEN REDUCED 6�'PAID CUIMS. iHSR �� TypEOFIN9UMNCE —� pOLiCYNVM1reER M �EFF P��%P u�17S GENERl1�W181LRY EACHOCC�MENCE S 1�Di�0 A X�COMMEftCIFLGENCMLlIA61LRY I CP070932 06l18172 �/�&�, pREM15 �� Ey4(Ea_seurce,wre7 $ . __. . �CLA�b13-0.YtDF, ' XJ OCCUR �.7E�E%P(Anyale pllS•on) S S_OO PER30NALPoAOVINJURY E O�DOO_00 Jl.iquortiab114y _ _ eEnere,�nGCRecarE , s 2,000_00 GEML�GREGA7ELIMIiAPPL1ESPER: PftOa1C75�.COMFiOPAGG 1 'I�OOD.O� POLICV vR0. lOC = �u7oMaei�uamuir . COM61NEOSING�EtMIT S �Ea ecdCeM) ��A��UTO 90DIL�IHIURY(Prcpx9ql) S ALIOWNE0AVf03 I BOOILYIN.tt1RY�Pyad5Wn1) i 9CHFABLE4 A�1T03 I PPOPERT'pAYAGE ..`I.s —'— _{I HINEOALITOS I (PefBOCldinl� �S—__ INON•OWNED NROS � __. x 4M&tElu1 tlA6 X 'OCCIlR EhCH OCCU0.RENCE i 1.000�00 E%CE391.wB ClAIM3-MPAF �RECiAT6 6 ��DO�QD a —1� — `uMolos7a ow+��a aeNarta — �uCTl9�6 I , .�. �' $ ' �_ '_� X R ENnON s WORKERSCOMPENSpTION I �STAT�' �m NNGEMP�OYERS'UABILrtY �QP�CUb]¢8_� ft .� /� ANYfRpPWETOR?ARTNE�F.%ECUPVEY'N �'+�$.�a4g�x I �8��3l�� &��1� E.L,EACHACCID6M S 509,00 OFFlCERR.1FAflERE%CLUDE07 � p�A � (NentltlOrylnNH� i EL.OISEOSE-EAEMPLD 3 5�0��0 If yas,tlClPI106 uMB! OESUt�PfqNOFOPEqATONS091ow F,L.o13eASF,•POIIC�LMR 5 SOO�OO OESLRIVTION OF OYEMTION91 LD�ATON5/VEX1CL65 (/1R�ch ACORP 107,�tqkeMl RNenMs ScnodWq ttmerc ep�c�la ropWmd� Re:416 Main Sbeat,Route 28,WsstYartnou}h,Mass.02673 CERTIFICATE HOLOER CANC�LLA710N SAMPLE- SMOULD ANY OP 7}IE ABOVE DE9CRIBED POLICIE$BE�ANCELLEO BEFORE """'"""$AMPLE"'"•"""""" THE EXPIRATIOM OATE THEREOF, NOTICE M1RL BE GEWERED IN ACCORDANCE WfTFI THE POULV PRONSIONS. AIITH^OpREwU RE�0.ESENfATNE l�— � 01988-2009 ACORD CORPORATION. AI{righta resBrved. ACORO 25(2009l�9) The ACORD name Antl logo are regtstered marks of ACORD