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Home My WebLink AboutApplication and WC � A�n,or�D sa�.�s a TOWN OF YARMOUTH BOARD OF HEALTH , �� APPLICATION FOR LICENSE/PERMIT -201�� [,3', [��[��J[�DD * Please complete form and attach all necessary documents by De be l5 I 3 �� Failure to do so will result in the return of youc app��aEiun pac ESTABLISHMENT NAME: �/�Gt.o'�i /7gL�6f2/6S US9 --iOP,A�f'KD..S/Y�STAX ID: �� ' � LOCATION ADDRESS: �°�/ H(/S117�7�'�. ��5' TEL.#: S O / MAILING ADDRESS:3°1�f4�/T1.(J6/�W_�'� YAl,ND��g. DZ/oCi OWNER NAME: CORPORATION NAME(IF APPLICABLE): �,y/�J 69.�IES c(s/1� ^ �NO40,Sht.� MANAGER'S NAME: � ��>/r� TEL.#: S08 �+a/-O��T MAILING ADDRESS: Slff� 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. 1. N�� 2. Pool operators must list a minimum of two employees cunently 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. �. u�n z.� 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 Service Establishxnents, 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. AI�F} 2. PERS9I�LRY_CHARGE: _ Each food establishment must have at Ieast one Person In Chazge (PIC) on site during hours of operation. 1. N�A 2. HEIMI.ICH 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 aad maintain a file at your place of business. 1. Al�f}' 2. 3. 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 _INN $55 _CAMP $55 _SWIMMINGPOOL �80ea _LODGE $55 _1RAII,ERPARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100SEATS $85 _CONTINENTAL $35 _NON-PROFiT $30 _>]00 SEATS $160 _COMMON VIC. $60 LWHOLESALE $80 ��a-� RETAII.SERVICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<SOsq.fr. $50 _>25,0(IOsq.fr. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 � _TOBACCO $95 NAME CHANGE: $15 AMOUNT DLTE _ $ SO.00 *►*;kPLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*+**�' ADNIINISTRATION ' 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 INSLJRANCE ATTACF�D OR WORKER'S COMP. AFFIDAVTT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PL.EASE CHECK APPROPRIATELY IF PAID: YES `� NO 11�'OTELS r*,IVB�T��:�LOF�G'.i4i�i;�7'r�BLISiivi IENTS 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 customazily 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 prior to opening. Contact the Health Department to schedule the inspection three(3)days pnor 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 standard plate count by a State certified lab, and submit[ed 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 obtamed 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 Pernut until the above terms have been met. OUTSIDE CAFES: _ -�ii1tSI(�ta.��.��I�:�.��6tltu2'ivi 5CutIII�2��T`rra"2iCZ�vtic'li��S 52I'ViCGj��iiYuSiila�FitlJfcRY�rPi7�-� i a C-a�B.2.0 vi-a�L'2iL�i. 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 REQUIRED FEE(S)BY DECEMBER 15, 2011. ALI_ RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING> NEW EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUII2E A STI'E P . DATE: /Z�S�lI SIGNATURE: �� PRINT NAME&TITLE:�[,2� % ("F1�1/.�'l-' Tc�72f/lD.��itil�s �,/�- Rev.10/25/]1 A�' CERTIFICATE OF LIABILITY INSURANCE °ATE`M""�°m��, izro�non THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLV 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 CER7IFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN 7HE ISSUING INSURER(3), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT:If the certiflcate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to �� the terms and conditions of the policy,certain policies may require an endorsement A sWtement on this certificate dces no[confer rights to the � certificate holtler in lieu of such entlorsement(s). �� PROOULER CONTAC� 9 AOII R15k S2fV1C25 C2lltfdl, IOC. �E� PhiladelPhia PA OffiGe pyc.No.ExtC C866) 283-A22 �.No.: CBd]) 953-5390 9 pnC Lif!¢f'Sy P1aC2 E-0WL p 1fi50 Md!'k2t Stf2Et ADDREbS: _ SUit¢ 1000 Ph1lddElphld PA 19103 USA INSURER�S�AFFORDINGCOVERAGE NAICN INSIIHED RSURERA ACE AIIIEI'ltdll msurance Company 22667 BBU, In<. on behalf txsuneae: Indemnity Insurance Co of North nmeriw 43575 of itself and u.5. subsidiaries including (see attached addendum) msunea c � 255 Business Center Drive ��ao: Ho!'Sham PA 19044 USA MSURER E: MSURERF: COVERAGES CERTFICATE NUMBER:570044588719 REVISION NUMBER: THI515 TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTIMTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. Limils shown are as requeatetl � TYPE OF IN8URANCE gg yyyp POLICY NUMBER M�,yp M LIMITS A GENERRLLIABILRY H�� EACHOCCURRENCE E1�OOO�OOO X GOMMERCIALGENERALLIABILITV PREMISES Eaoxu�rcnce 51�000�000 GtAIMSMA�E %❑OCCUR � MEO EXP(Anyoneperson) $5,000 PERSONALBADVINJURY SS�OOO�OOO � . GENEftALAGGREGATE E10�000�000 � GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-GOMPIOPAGG 52,000,000 Q POLICY PRa X LOC o r A AUTOMOBILELNBILT' ISA HO S GOMBINEDSINGLELIMR � Eaec'iaent E5,000,000 x ANYAUTO � BODILVINJURV(Perparson) _ ALLOWNED SCHEDOLED BODILVINJURV(ParaxkenQ AUTOS AUTOS � NON-0WNEO PROPERTY DAM4GE V HIREDAlR05 qpTOS Perecotlmt — C m UMBRELLALIAB OCWR . EACHOGCURRENCE V E%CESSLWB GWIMSMADE AGGREGATE DED RETENTION B WORKERSCOMPENSATONAND WLRC4646983$ 0 1 11 1 1 N/C STATLL OTH- p EMPLOVERB'�wBiurv y�N SCFC46469859 02/O1/2011 02/O1/2012 x TORYLIMITS ER . A OFFICEWMEMBER/EYCLU�EOi�cun� �N/A wLRC46469847 02/Ol/201102/Ol/2012 EL.EACHACCIDENT $1��00.�00 . (MmEa�aryinNX� E.LDISEASE-EAEMPLOYEE E1�OOO�OOO Ifyen,Eeacn'Leuntler �ESCRIPTIONOFOPERATIONSMbw EL.DISEASE-POLICYLIMR SS�OOO�OOO� _ � OESCRIVTION OF OPERATION51 LOCATIONS I VEHICLES(Albch ACORD 101,AEEitlonal Remarks Schetluk,M mort space is requlreE) � ��1p� y •� ��e CERTIFICATE HOLDER . CANCELLATION y� SHOUID ANV OF THE ABOVE OESCNBED POLICIES BE CANCELLEU BEFORE TXE EXPIRATION DATE TFEREOF, NOTICE 1MLL BE UELIVERE� N ACGOROANCE WITH THE POLIGY PROVISIONS. Th2 CoIiII�aOwealth of Md55dChU52tt5 . AUTHORQEDREiRESEMATNE Department of industrial nttiden[s Office of Investigations � �� 600 Washington Street, 7th Floar BoSion MA 02111 USA � IN�6tl Osn �7965-2070 ACORD CORPORATION.Ail rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD MSUNED aau, inc. on behalf . of itself and u.s. subsidiaries including (see attached addendum) � 255 eusiness Center Drive Horsham va 19044 USA Named Insureds rhe following are Named xnsureds under the mentioned policies: � Advantafirst Capital Financial Services, inc A11E11 FOOdS IOC APf101d FOOdS COmpdny, InC . AI'nOld P!'OduCts, InC nrnold Sales Company inc sri� rransport, mc aimbo aakeries USn, inc simbo eakeries oistribution Management, ��C - eimbo eakeries oistribution company, �id aimbo Foods sakeries oistribution, inc � Bimbo Foods aakeries, xnc - aimbo Foods, inc aimbo Foods, LLC eutter Krust eaking Company Inc. Carlisle Foods xnc Charles Freihofer aaking Company, inc � Earthgrains vernon, LLC earthgrains eaking Companies, Inc. � Earthgrains Bakery Group, Inc. . Edl'thgfdifl5 DiStfibuti0n, LLC � EGR California Region Support Services, xnc. Ent2nmdnn'S Pf'OdUCtS, InC Entenmann'S Sales Company, Inc � Entenmann'S InC � Freihofer Products, inc Freihofer sales company, inc � htid-�ulf sakery, LLC Orograin sakeries Manufacturing, inc orograin sakeries Products, xnc Orograin aakeries Sales, inc � � POtOmaC FOOdS, LLC . Safa Lee Vefnon, LLC SB NV InC stroehmann Bak0fie5 P.A. LLC � stroehmann aakeries , inc 5troehmann aakeries , �c Stroehmann Line-Haul, L.P. stroehmann Sales ��c � 7ia 2osa eakery of Ohio., rnc westfield Foods ��C Certificate No: 570044588719