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Home My WebLink AboutApplication and WC � �, ^' � TOWN OF YARMOUTH BOARD OF HEr�L,TH = � �0' � APPLICATION FOR LICENSE/PERMI'I'T 2 1 � � , t � � , * Please complete form and attach all necessary docpm � ece ber�YS 2Dr0. " Failure to do so will result in the retum of your application p c e�{EALTti DE�T. ESTABLISHMENT NAME: �/,fi/�{(7 �v?nf'l,Li�-S f/s/f --fl/��Je[O.SA�STAX ID: � LOCATIONADDRESS: 37 Nci,vr/NGrnI/ �U'� TEL.#: SD� 395�o79i MAILING ADDRESS: S Ysl/I.i�cQ11j/y � NLt GJB(o!o✓ OVVNER NAME: CORPORATION NAME (IF APPLICABLE): 3,Lo18p /�d9E'�it�s i>sg MANAGER'S NAME: �(,g,� L?.�.euC� TEL #: ,�pg ��_6�a�- MAILINGADDRESS: 37 ��/,!/IlA/6T7�.L/ ��F' { y�(Z�/�f� .qi1A nZ�z,c/ POOL CERTIFICATIONS: The pool supervisor must be certiGed as a Pool Operator, as required by State law. Please list the designated _ Pool Ope_rator(S-)-and attac_h a copy of tlie certification to this form. . l. iUf/� 2 Pool operators must list a minimum oft�vo employees cun-ently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee certifications to this foiYn. The Health Department will not use past years' records. You must provide new copies and maintain a file at y°our place of business. 1._1�� 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments az•e required to have at least one fiill-tune employee who is certified as a Food Protection Manager, as defined 'ui 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 Gle at your establishment. i. N�R 2. PERSON IN CHARGE: Each food establishment must have at least oue PersonZn Charge (PIC) on site duiing hours of operation. l. /I�/� 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 tnnes. 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 Gle at your place of business. 1. NI� 2. 3. 4. RESTAURANT SEATING: TOTAL # N l} OFFICE USE ONLY LODGL\G: LICENSE REQUIRED FEE PERMIr= LICENSE REQUIRED FEE PER�IIT* LICENSE REQUIRED FEE PE&'�fIT g _B&B S55 _CABIN 555 _MOI'EL S55 _� _I1GN S55 _ . .CAMP . $�j . ___S�i�'LVIMINGPOOL S80ea. _LODGE S5� �IRAII,ERPARK 510� 9 _\LZ-IIRLPOOL � S80ea. FOOD SER�'ICE: LICENSEREQLRRED FEE PERI�III"= LICENSEREQUIRED FEE PERA9T?� LICENSEREQUIRED FEE PE&�I[I'= _0-100 SEArS S85 _CONI'INENI'AL S35 NON-PROFII' S30 _>100 SEATS S160 _COibIl�10N�7C. S60 �R'FIOLESALE S80 I�' j�6� RETt1IL SER�ICE: —RESID.KITCHEN S80 LICENSE REQUIRED FEE PER�IIT# LICENSE REQUU2ED FEE PE&�III'= LICENSE REQUIRED FEE PERbIlI'_ _�SOsq.R. S50 _>25,OOOsq.B. S??5 VENDING-FOOD S?5 _Q5,000 sq.R. S80 _FROZEN DESSERT S40 I'OBACCO S55 �A�1E CHA\GE: S15 AMOUNT DUE _ $ SO. Oo ""***PLEASE TtiR\O�'ER 9SD CO�IPLEiE O'IHER SIDE OF FOR�1"**** ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or perniit 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 AFF�DAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSiJRANCE ATTACHED ✓ OR WORKER'S COMI'. 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 M�TELS AND l7'1'HER LODGIlVG 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 Department to schedule the inspecUon three(3)days pnor to opening. PLEASE NOTE: People aze NOT allowed to srt 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. PUOr.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 Departmem 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.yarmouth.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 resuks submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pemrit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prio:approval from the Boazd ofHealth. OUTDOOR COOHING: Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. NOTICE:Pernuts run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBIIITY TO RETIJRN THE CONSPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2010. ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIR SITE . DATE: !�" Z U SIGNATURE: � PRINT NAME&TITLE: /1/.1,1/ J �,hCc%�' TCas,�rl0�-��Ps ,!/�6f'� io�o6�10 "��' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D�/YYVY) ivn¢mo THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER THIS CERTFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF IN3URANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IS3UING INSURER(S), AUhIORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT:tt the certifiwM 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 statement on this certificate dces not confer rights to the � ceRificate holder in lieu of such endorsemenGgl• c PIYOOUCER ��A�T a A00 R15k 5¢fviCCS C¢nVdl, IIIC. PIqNE (g66) 283-]122 F� (84]) 953-5390 0 Philadelphia rn office �^��+^�� p One Libet'ty PlaCe E�� p 1650 Mdrket Stre¢t PRODUCER 570000039695 = SUISE 1000 WSTOMERID:i: Vhlladelphld PA 19103 USA INSURER�S)AFFORDINGCOVERAGE NAICit i��o INSURER0. ACE Ameritan Insurance Company 22667 BBU, Inc, on behalf Ir�sunene: Indemnity Insurance Co of North America 43575 of itself and U.S. subsidiaries including (see attached addendum) �+suneac: 255 eusiness Center Drive HO�Shd�ll PA 19044 USA WSURERD: MSURER E: INSURER F: __. _.— __" __.__ _. __ . _._._—..__ —_._ ___— . —.._ .__..__._ COVERAGES CERTIF�CATE NUMBER: 5�0040783595 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN�ICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANV CONTR4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLP.IMS. Limib shovm are aa rpuesb LTR TYPE OF INSIIRANCE INS NNO PoLILY NUMBER Mhyp M�,yppryyyy LIMRS GENERAL LU1&LITV E4CH OCCORRENCE COMMERCNLGENERALLNBI4TY PREMISES Eaoaurimm CWMS-M4DE ❑OCCUR MEOEXPl�lnyanepenon) PERSONAL 8 ADV INJORV q � GENERALAGGREGATE m n GEN'LAGGREGATELIMITAPPLIESPER: PRO�UQS-COMP/OPAGG Q POLICV PR0. LOC S n AUTOMOBILE LIFBLLITY COMBMED SINGLE 4Mf! � �mem ANV AUTO BOOILYINJORY(Perperson) O Z ALLOWNEDAUTOS BODILYINJURY(Pe�auAtlenQ m SCHEDOLED AlIT05 PROGERtt OAM4GE A NIREDAUTOS Paracdtlent V C NONOWNEOAUTOS � � UMBRELLALIAB OCCUR ENCHOCCIIRRENCE EXCESSLIAB CL4IMSJMDE NGGREGNTE DEOUCTIBLE RETENTION B WORI�R3COMPENSATIONAND WLRC46131848 0 1 1002 Ol 2011 WC STATU- OTH- p EMFLOreR3'unelLm y�N WLRC46131824 02/O1/2010 02/O1/2011 X TORVLIMRS A OFFICERrME BEBE%CLVOE�t�CM� �NIA SCFC4(131636 02/Ol/2010 Q2/Ol/2011 E.L.E4GHACCIOENT $1�0�0�0�0 �MaMaroryinNM E.L.DISENSE-EAEMPLOYEE $Z�OOO�000 If yes,tlescnba uneer OESCRIPTIONOFOPERATIONSbebw E.L.OISEASE-PO4CV4MIT $S�OOOr�00 r� DESCWPTION OF OPEMTIONS/IOCpTI0N91 VEMCLE3�Attech ACORD 101,AGNtionel Remerka SCMtl�b,if more apace ia requMeE) CERTFICATE HOLDER CANCELLATION � SXOULD ANY OF TXE ABOVE DESCRIBED POLIGIES BE CANCELLED 6EFORE TNE E%]IRATION DATE THEREOF, NOTICE WRL BE DEWERED M ACGORDANCE W1TH THE . PO4LV PROVISIONS. ti Town Of Vdfllbuth pUTIqRQEDREPRE3EMATIVE 1146 Route 28 5outh varmouth rnn 02664 u5n � �� 07986-2009 ACORD CORPORAT70N.NI rights reserved. ACORD 25(2009/09) The ACORD name and logo are�egistere0 marks of ACORD INSURED BBu, inc. on behalf of itself and u.5. subsidiaries including (see attached addendum) 255 9usiness center orive HofSham PA 19044 USA r+amed xnsureds rhe following are Named xnsureds under the mentioned policies: ndvantafirst capital Financial 5ervices, Inc allen Foods inc Arnold Foods company, inc arnold aroducts, inc nrnold Sales Company xnc ati� 7ransport, Inc Bimbo sakeries usa, xnc eimbo aakeries oistribution wanagement, ��c simbo aakeries oistribution Company, �td aimbo Foods Bakeries Pistribution, inc eimbo Foods eakeries, inc aimbo Foods, Inc simbo Foods, LLC carlisle Foods rnc charles Freihofer eaking company, inc - _ _ _ ._ . _ . . Entenmann'S Products, Inc . _ . _--- __ __.__ _.___-- - -- entenmann's Sales Company, inc Entenmann'S Inc Freihofer rroducts, Inc Freihofer sales company, inc wid-Gulf sakery, LLG orograin eakeries Manufacturing, inc Orograin eakeries vroducts, xnc Orograin sakeries sales, inc aotomac Foods, LLC sa Nv inc stroehmann aakeries P.A. LLC Stroehmann sakeries , inc stroehmann aakeries , LC Stroehmann �ine-Haul, L.P. stroehmann sales ��C 7ia 2osa aakery of Ohio, inc westfield Foods ��C Certifica[e No: 570040783595