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Home My WebLink About2007 Licensing . _ [�a�+y �`r Ry TOWN OF YARMOUTH BOARD OF HEALTH = o APPLICATION FOR LICENSE/PERMIT-2U07 � � .:�� a#t��'OiJAN 0 2 2007 �� * Please complete form and attach all necessary documents by Dece�b�er 31, 2006. Failure to do so will result in the return of your application packet. NAME OF ESTABLISffivIENT: QQ��,L, �/�� TEL. #5oS 3`"r y l ln7 S LOCATION ADDRESS: 1� ��crrES Pl}Ti�i UV1i T .� v Llc�rm�v`ffh, YYIA- D�?(n�v�f MAILING ADD S: OWNER NAME�I CI-��`i 2 D i._._ 1�E IL��/ �2 TAX ID (FEIN or SSNI: �/� / CORPORATION NAME (IF APPLICABLE): ^ J MANAGER'S NAME: TEL. # ��. IviAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law,�}ease list the designated Pool Operator(s)and attach-a ce�gt�fthe-certification4o-this-form: , 1. 2. ✓ l Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee ceRifications to this form. The Healt6 Department will not use past years' records. You must provide new copies and maintain a£de at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments aze 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. 17�e Health Department wili not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSO�+I�d CHARGE: ___ _ _ _-- _ Each food establishment must have at least one Person In Charge (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 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 Heaith Department will not use past years' records. You must provide new copies and maintain a Tde at your place of business. 1. 2. 3. 4. RESTAtTRANT SEATING: TOTAL# --'CT'— OFFICE USE ONLY LODGUIG: LICENSE REQi)IItF.D FEE PERMI7'# LICENSE REQUIl2ED FEE PF.RMIT k LICENSE REQUII2ED FEE PERMIT N _B&B S50 _CABIN $50 _MOTEL $50 _INN $50 _ _CAMP $50 _ _SWAIIviQdGPOOLE75ea. _LODGE $50 1RAII.ERPARK $100 _WfIIRLPOOL $75ea. FOOD SERV[CE: LICENSE REQUIltED FEE PERMIT# LICENSE REQUIItED FEE PERMIT'# LICINSE REQIARF.D FEE PIItMI'L# I 0-1005EATS $75 � O7'IJ(� _CON1'INENTAL $30 _NON-PROFIT S25 >I00 SEATS SI50 COMMON VIC. S50 WHOLESALE S75 RETAII.SERVICE: —RESID.KITCIIE;N $75 LICINSE REQi7Il2ED FEE PERMIT# LICENSE REQiJIltF,D FEE PERM[T# LICINSE REQiJIItF,D FEE I'ERM[1'f! _<50 sq.ft. S45 _>25,000 sq.ft. $200 _V&NDING-FOOD $20 _QS,OOOsq.ft. S75 _FROZETIDESSERT S35 TOBACCO $50 NAME CHANGE: S10 AMOUNT DUE _ $ 75.00 •"'"PLEASE 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 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 INSLTRANCE 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. PL.EASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS 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 demonstrate that they maintain a principal place ofresidence eLsewhere. Transient occupancy shall generaily 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 ins ed by the Heakh Department prior to opening. Contact the Health Department to schedute the inspection five(S�ys pnor to opening. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool snust be drained or covered within seven(7)days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Aeaith 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. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the suspension ar revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approvai from the Board ofHealth. OUTDOOR COOKING: Outdoor cooking preparation,or displag of any foqd product by a retail or food service establishmern is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 31, 2006. ALL RENOVATIONS TO ANY POOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TF�BOARD OF HEALTH PRIOR TO COMNIENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ( � `Z�`4 'P SIGNATURE: �r�'"� PRINT NAME&TTfLE: /�ff9--2D �K�L�}i�f� ��UrU�2 10/17/06 . From:Cenler Insu2nce Agency To:Fa�dF15083947687 Date:12113I2006 Tme:134:12 PM Page 1 of 1 ACORD CERTIFICATE OF LIABILITY INSURANCE °"'�,"�°°"""" *M 12/4106 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Center Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 424 Fountlry Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. N.Easton MA 02356 INSURERS AFFORDING COVERAGE NAIC# wsurseo BAGEL BAY wsuaean: AIM MUTUAL INS CO � 20 MARJORIE AVE wsuaea e�. INSURER C POCASSET MA 02559 wsuaea o� INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD IN�ICATED.NOTNIITHSTANDING ANY REOl11REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICN THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES UESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOVJN MAV HAVE BEEN REDUCED BV PAID CLAIMS. MJSR 0'L POLICYEFFECTIVE POLICVEXPRtATON POLICV NUM6ER LIMRS GENERALLINBILrtY EACHOCNRRENCE $ DPN4GE TO REN�ED COMMERQALGENERALLIABILITY PR M r $ CLAIMS MA�E �0(xUR MED EXP M one erson $ PERSONHL 8 ADV INJURY $ GENERPLAGGREGATE $ GEMLAGGRE6ATELIMITPPP�IESPER- PRODUQS-COMP/OPA6G $ POLICY PRd LOC AUTOMOBILE LIABILRY COMBWED SINGLE LIMIT ANVAUTo (Eaeooi4eM) � ALL ONMED NROS BODILY INJURY SCHEDULEDAUTOS (Perperson� $ HiRED AUiOS BODILYINJURY $ NONOWNED PU�OS (Per accitlenry PROPERTY DPM4GE $ (Pe�eccitleM� GFRAGELIA91LrtY AUi00NLY-EAACCIDEM $ ANYAtRO OTHERTHPN �ACC $ NROONLY: qGG $ EXCESSNMBRELULIN8ILRV FACHOCCURRENCE $ OCCUR �CLAIMSMPDE AGGREGATE $ $ OEOl1CTIBLE $ RETEMION $ $ WORKERSCOMPENSATONMIO WCSTNiLL OM A EMPLOYERS'LIA9ILRV yWC601053207 �rJ�2��s OrJ�2e��7 E1.EACHACCIDEM $�0��0�� PNV PROPRIEfOR/PPRTNEWE%ECl1TIVE OFFlCERMIEMBER EXCWDE�9 E.L.�ISEASE-EA EMPLOVEE $�OO,OOO ISPECIPLSROVISIONSbelow EL.DISFASE-POLICYLIMIT $SOO�OOO OTHER OESCRIGTON OF OPERATIONS/LOCA110N5/VEHICLES/E%CLUSIONS ADDED BY ENDORSEMEM/SPECIAL PROVISIONS BAGELSHOP CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRI6E0 POLICIES BE CANCELLED BEFORE THE EXPIRATON TOWN OF YARMOUTH DRTE TIEREOF,T1E ISSINNG INSl1RER WILL ENOERVOR TO MRIL �� OAVS WRRTEN 1146 ROUTE 128 NOTCE TO TME CERTIiICATE HOLDER NAMEO TO TXE LEFf,BUT FAILURE TD DO 30 SXALL SOUTH YARMOUTH MA 02664 irnrose No oei ' FAX TO: 508394-7678 qeaqeseerrnm ��v'/''l AIRXORIIEO REf ACORD 25(2001/08) OACORD CORPORATION 1968 TOWN OF YARMOUTH BOARD OF HEALTH PERNIIT TO OPERATE A FOOD ESTABLIS�NT PERMIT NUMBER: #07-132 FEE: 75.00 In accordance with re�u1ations promulgated under authority of Chapter 94,Section 305A and Chapter 111,Section 5 of the�eneral Laws,a peimit is hereby granted to: . _ Richazd L. Kelley, 7r., 12 White's Path, Unit 2 South Yazmouth, MA Whose place of business is: Baeel Bav Type ofbusiness: Food Service To operate a food establishment in: Town of Yarmouth Permit expires: December 31 2007 BOARD OF HF,AI,TH: B $. iN.$., ' SEA��: o ��s� .��., �'v�er� xEsnucnoxs: see reaerse s;ae. Role�t�s. B+u+arn„ G/� Pat�+rc,4�No$� �tf�*�,, R.N. Mazch 30.2007 Bmce G. �uphy RS.,CHO Director of Health