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Home My WebLink AboutApplication and WC � ' �3C�� TOWN OF YARMOUTH BOARD OF HEALT� .,� , APPLICATIONFORLICENSE/P�,�II�'"•2012 r;��f 2 � ZO�� ` �� . �. * Please complete form and attach all necessar�d�cu�� IY�Dece� be Failure to do so will result in the return�yo applicahon p . ESTABLISHMENT NAME: Cl�ie�S P �r,f R� � LocaTiorr.�D�ss: S ovT� C�fST A �I TEL.#: � 7S // MAILING ADDRESS: �' Gt�E A MQ 7 owrr�x rraME: /,'N�zvc. �l�N N��nJ ��-C�u,e�e�n� CORPORATION NAME (IF APPLICABLE): /L /f7 P/R.ITS � , MANAGER'S NAME: ,C L CJ �'AR.2.� TEL.#: - MAII.ING ADDRESS: S � /!/l p0i2T kPOOL 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. 2. Poo( operators must list a minimum of two employees currently certified in basic water safety, standazd 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' rewrds. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. y 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 attach copies of certification to this application. The Healt6 Department will not use past years'records. You must provide new copies and maintain a file at your establishment. ]. 2. _ PER�ON IN CHAR�'iE: _ -- _ ___ _ _ -- -- -- Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 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 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 tile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGWG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# _B&B $55 _CABIN $55 _MOTEL $55 _1NN $55 _CAMP $55 _SWIMNIWGPOOL $80ea. _LODGE $55 _TRAII,ERPARK $105 _WHIRLPOOL $SOea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CON'1'INENTAL $35 _NON-PROFIT $30 _>]00 SEATS $]60 _COMMON VIC. $60 _WHOLESALE $80 RETAIL SERYICE: —RESID.KITCHEN $SO LICENSE REQUIRED FEE PERMIT# LICENSE REQIJIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � <50 sq.ft. $50 . ra-o�� _>25,000 sq.ft. $225 _VENDING-FOOD $25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 �TOBACCO $95 ,�1�0 NAME CHANGE: $15 AMOCJNT DUE _ $ 1'�5 •00 •**�xPLEASE 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 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 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 .�,ND OT'HEii LODGING E3TABLISI�'iLI�NTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinazily 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 OPEIVING: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 aze 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. CAT'ERING POLICY: Anyone who caters within the Town of Yannouth 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.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 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: On�sruei�uo :�:;:,-cutdcors�aa,-tgw��.�.ait.;�;wa:sessserv:ce;,m:ast::a:Fepricr.•apprevalfromr.heBoardofHealth. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from 7anuary 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2011. AL,L 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 COMMENCEMENT. RENOVATIONS MAY QUIltE S E LAN. „ /�C DATE: l o� � �� SIGNATURE: /�✓O�1- /'�/ PRINT NAME&TTI'LE: E L ONJI�cS �C � /�S/QE Rev.10/25/11 ....._ -_---....__, . _.._.__..._....._. -m-- ��1 OP ID: AD '`�`,�.,.�'R�' CERTIFICATE OF LIABILITY INSURANCE onre�rMioaww> „nen, THIS CERTFICATE IS ISSUED AS A MATTER OF INFORMATiON ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER. THIS CER7IFICATE DOEB NOT AFFIRMATVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER TME COVERAOE APFORDED BY THE POLICIE3 BELOW. THIS CER7IFICATE OF INSURANCE DOE8 NOT CONSTITUTE A CONTRACT BETWEEN THE 133UING INSURER�3), AUTHORIZED REPRESENTATVE OR PRODUCER,AND THE CERTRICATE F10LDER. IMPORTANT: If the cerllflcate holder Is an ADdTONAL INSURE0. the pollcy(les) must be endorsed. If SUBROOATON IS WANED, subject to the tertns antl condltlons of the polley, certaln policles may require an endwsement. A stateme�rt on tMs certiflcate does not confer rlgMs to lhe certlflcate holtler in Ileu of such endorsemeM S. 'RODUCER 7e�_ZQ'�j_6.�.'{� NRME: VM. F. Borhek Insurence Agency 78�_29&2�� a o� 11 Poymouth Street lalifax,MA 02338 E.MWL �cottCCasagrande °W°�� .BECKE-1 WSURE SAFFORDINGCOYERAGE WJC� NSUflED BeckersPackage3tore INSURERA:GI'E8tAR1@fIC911It19.00. 31 PoIIyFlskLane wsuaerse:MaseRetallMerchants Dennlsport,MA 02639 INSURERC: INSURER D: INSURER E: :OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT iHE POLICIES OF NSURPNCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICV PERIOD INDICATED. NOiWRHSTPNDING ANY REQUIREMENT,TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WtTH RESPECT TO WHICH THIS CER7IFICATE MAY BE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERENJ IS SUBJECT TO ALL THE TERMS, EXCLUSqNS AND CONDRpNS OF SUCH POLICIES.LIMRS SHOM/N MAYHAVE BEEN REDUCED BY PAID CIAIMS. R TYPE OF INSURRNCE POLI POLICV EXP UMITS GENERRLLIRBI�ITV EACHOCCURRENCE S � 'I�WO�OO � COMMERCIALGENERFILIABILITY PP7565778 �O/Y'I/N 'IOIL'INZ pREMISESEeottunenca S SOO�OO CLAIMSMAOE �OCCUft MEDEXP�Anyaneperson� E � �0�� X BUSIfIB88 OW fIBfB PERSONA�&ADV INJURY S ��OOO�O GENERnLFGGREGATE S 2�000�0 GEN'LAGGREGATELIMITAPPUESPER' PRODUCTS-COMPIOPAGG $ Z��OO�O X POLICY PR� LOC s AUfOMOBILELiRBILIT/ COMBINEDSINGLELIMIT s (Eaeccitlent) ANY AUTO 80DILY INJURY(Per person) E ALLOWNEDAUWS 80DILVINJURV(Peraccitlem) S SCHEDULED AUTOS PqOPERTY DAMAGE X HIRED hUT05 (Parettitlertl) $ X NON-OWNEDPUTOS $ E UMBRELLALIAB pCCUR EFCHOCCURRENCE S EXCESSLWB CLAIMS�MADE AGGREGATE E DEOUCTIBIE $ NT $ WORKERSCOMPENSA770N WCSTAN- OTN- ANDEMPLOYERS'LIABIIRY X TORVLIMTS ER 3 PNYPROPRIETORIPPRTNER/EJ�QIPVE Y� 140006023037 ��/�� 0�/��/�Z E.LEACHFCCIDENT $ ��0 OFFlCQ2/ME1.18EREXCIUCED'! NIA (ManEatoryinNH) El-DISEASEEaEMPIOVE $ 7U�,OO II ye5.descnbeunJar DESCRIPTION OF OPERATIONS belav E.L.OISEASE-POLICV LIMIT S SOO�OO P OP R � �8CRIPTIONOFOPERA Na��oepn�sivewe�@eq_pec0260�R'DtO1,AtlWnonslWmvksBehsauls,Hmonsvaeslsroquiratl) �tore Location: 48�aet Mam ., Hyanms, MA " TIFI ATE TOWNYAR SHOULD ANY OF TXE AHOVE DESCRIBED POLICICB BC CANCELLED BEFORE TOWN OF YARMOUTH 7ME EXPIRATON DA7E TXEREOP, NOTICE WILL BE DFLIVERED IN ACCORDANCE WITM T1E POLICY PROVI&ONB. 1146 MAIN STREET.RTE.28 S.YARMOUTH��MA O'ZBB$ qIJ�HORIZEUREPRESENTA7IVE Scott C Casagrende �1888-2009 ACORD CORPORATION. All rigMa reserved. 4CORD 25(2008/09) The ACORD�mme end logo are regiatered marks of ACORD