HomeMy WebLinkAboutApplication and WC � /�p TOWN OF YARMOUTH BOARD OF HEALTH ������� � ���
�� APPLICATION FOR LICENSE/PEI�II�� { r�� ` ,,�.� �
� * Please complete form and attach all necessary docu ber EPT.
Failure to do so will result in the return of your applicauon p
ESTABLISHMENT NAME: /.�uC�C /SGA�/� �eu�Y c�Ye�R TAX ID: �
LOCATION ADDRESS: S�h' �rre.r /SL�to Qo TEL.#: Sa� �9a 8��.�
MAII.ING ADDRESS: la1t��T Y.Y.���!�r , m�-o7�3-3
OWNER NAME: E�i �1��!
CORPORATION NAME(IF APPLICABLE): G�lG`' M�-r'' CdCo /�-
MANAGER'S NAME: Ev�2 C,rn�nj TEL.#: Sd�r �-�6 3!S(�
MAILING ADDRESS: .PsNwc,+ .ar ,u�t0l/L� '
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.
l. 2.
Pool 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' records. You must
provide new copies and maintain a�le at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - 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 Sanitazy 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 file at your establishment.
1. 2,
_ PER�QN IN CHARGE� _ ___— _ _.___--. _. — ------- _ -
_, _ .__�—
Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee uained 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. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABW $55 MOTEL $55
_INh] $55 _CAMP $55 _SWIMMINGPOOL $80ea
_LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT k LICENSE REQUIRED FEE PERMIT#
_0.100 SEATS $85 _CONTINENTAL $35 _NON-PROFPf $30
_>]00 SEATS $160 _COMMON VIC. $60 _WHOLESALE $80
RETAII,SERVICE: —RESID.KTI'CHEN $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<SOsq.ft. $50 _>25,OOOsq.ft. $225 VENDING-POOD $25
�Q5,000 sq.ft. $80 �Ia'�3 _FROZEN DESSERT $40 � �TOBACCO $95 �O
NAME CHANGE: $15 AMOi1NT DUE _ $ I'7S.Ga
•*•*#PLEASE TURN OVER ANll COMPLETE OTHER SIDE OF FORM�*+•*
.
ADNIINISTRATION � � �
Under Chapter 152,Section 25C,Subsection 6,the Town of Yazmouth 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 COMPLEI'ED AND SIGNED, OR
CERT. OF INSURANCE ATTACHE:D
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
14iO3'ELS AiVTi? fiTIi�Tt LC)DGIIvG�+53'A73LISFIh�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,ordinarily and customarily 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 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 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 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 OPEIVING:
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 Yannouth 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:
�utsi3e .,cs€�{i:�,��e:�sti.�tg�.�iY.h:�iter/:uzi�essservice;xr.ust�:-averrie:a��re��fFem�+eRe�r�ef�aith.
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 RESPONSIBILITI'TO RETURN
THE COMPLETCD RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 15, 2011.
Ai i. RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT, ETC.),MUST BE REPORTF.D TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
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DATE: r�o2 — 8— aa7/ SIGNATURE: �(�L�
PRINT NAME&TITLE: �v'�Yy K N�I �
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Department of(ndustrial Accidexts
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600 Washington Street, �"Floor
� Boston,Moss. 02111
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,, <`c RO o� CERTIFICATE OF LIABILITY INSURANCE DATE�MMNDIYYYY)
11/30/2011
�I THIS CERTIFICATE IS ISSUED AS A MATfER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIPICATE HOLDER. THIS
I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
'��. BELOW. THIS CERTIFICATE OF INSURANCE DOE5 NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�, 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 pollq,certain pollcles may require an endorsement. A statement on this certificate does not conter rights to the
� certificate holder in lieu of such eodorsement s.
PRODUCER
NPME:
I Eastern Insurance Group LLC-Main PHONE Fnx
��. 233 West Central Street - - ac r+o: - -
E�MAIL
'�, Natick MA 01760 ADDRE33:
I INSURE S AFFORDING COVERAGE NNC K
���. INSURER R:
�'i, INSURED '25'209 INSURERB:
I We Mart Corporalion Inc INSURER C:
! Buck Island Country Store INSURER D:
� 528 Buck Island Road
'��. West Yarmouth MA 026733353 �NSURER E:
'. INSURER F:
' COVERAGES - . CER7IFICATE NIJMBER:1196834047 REVISION NUMBER:. .
� THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD
INDICATED. NOTWITHSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAV BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS.
INSR FODL UBR PO�ICYEFF POLICYEXV
� LTR TYPE OP INSURANCE � �N POLICY NUMBER MINDDIYYYY MINDD/YYYY ��M�Tg
�� A GENERALLIABILITY W7073588 /5/2012 /5/2013 EqCHOCCURRENCE $1000000
���. x COMMERCIALGENEFWLLIA&LITY PREMI E E occu�nce Y300000
', CWMS�AADE �OCCUR MEDFXP(Myanepe�son $10000
�I PERSONPLBADVIWURY $1000000
''��� GENERALAGGREGATE $2000000
I GEMLAGGREGATEIIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2000000
I POLICY ��� LOC s
II B RUTOMOBILELIpBILITY 2093183414 /1/2077 /1/2012
Ea accitlent 1000000
��, ANYAUTO BODILYIWURY(Perperson) $
'i /LLLOWNED x SCHEDULED BpDILVINJURY(Peraccitlant) $
' AUr05 nUTO$
, X HIREDNUTOS x p�TO WNED ParacEc�j AMAGE $
$
' UMBRELLALI/.B ppCUR EACHOCCURRENCE E
EXCESS LIAB CLAIMSMADE AGGREGNTE $
DED RETEMION$ $
C WORKERSCOMVENSATION BWECNK2265 /5/2012 /5/2013 % '�STATU- OTH-
ANDEMPLOYERS'LIABILITY y�N
NNVPROPRIETORIPARTNERIE%EWTNE E.LEACHACqDEM $100000
OFFiCEfUMEMBEREXCLUOE�? � N�A
(ManWtoryinNH) E.L.DISEPSE-EAEMPlOYE $'100000
� ttyes,tlescnEeunGer �
� DESCRIPrIONOFOPERATIONS�elox E.L.DISEASE-POLICVLIMIT $500000
��,i DESCRIPTIONOFOPEMTIONS/LOCATIONS/VEHICLES �AttachFCORUtO1,AtltliUonalRema�kaStheCule,ifmorespaceiareq�iretl)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
��, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
'�, Town of Yarmouth ACCORDANCE WITH THE POUCY PROVISIONS.
'�� Board of Health
'i, 'I'I�IER�ZB AUTHORIZEDREPRESENTATIVE
���. S.Yarmouth MA xxxxx
'�, -�'u��QMn�.
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