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Home My WebLink AboutApplication and WC (3. �2 . PizzA " TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERNIIT—2Q 0 �� o(� "Please complete form and attach all necessary documenEs by ec er 9. ,� Failure to do so will resuk in the retum of ppur ap�licahon p � NAME OF ESTABLISHMENT: � T . — LOCATION ADDRESS: ,L MAILING AADRESS: OWNER NAME: � TA ID (FEIN or SSNI�� CORPORATION NAME (IF APPLICABLE): �� MANAGER'S NAME; TEL. # MAILING ADDRESS: 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 certificarion to tlris form. 1. 2. Pool operators must list a minimum of two employees currently certiSed in basic water safety, standard First Aid and Community Cardioputmonary 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 61e at your place of business. ,,,� 1. 2. ' 3. 4. � 3 FOOD PROTECTION MANAGERS - CERTIFICATIONS: � � All food service establishments are required to have at least one full-time employee who is certified as a Food p Protecrion Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. �� Piease attach copies of certificarion to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. ✓►� l.h�(,t fl,[�1 ��,�JC1,r.re 2. '��'��F�l'1'�l./L,�2� ��^ PERSON IN CEiARGE, y Each food est lishment must have at least one Person In Charge(PICj on site during hours ofoperation. � 1. 2. ��df� 7/1llGf�l�i?�J//� � c�9 HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heunlich Maneuver on the premises at all t9rr►es. Please list your employees mained in anti-chokmg procedures below and attach copies of employee certificadons 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. �. ��c��A ��.�_ , .S r� 2. 3. 4. RESTAURANT SEATING: TOTAL # �i�� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQL)IRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 L^TN S55 _CAMI� S55 _SWIMNIINGPOOL S80ea. _LODGE $55 _TRAII.,ERPARK $]OS _WHIRLPOOL SSOea. FOOD SERVICE: � LICENSE REQUIltED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0.100SEATS $SS �.�10-CI(F$ _CONI'INENTAL S35 NON-PROFIT $30 _>1005EATS $160 �COMMONVIC. $60 ��n_ni3- _Wj-IOLESALE $80 RETAII.SERVICE: —RESID.KITCHEN S80 LICENSE REQUIILED FEE PERMIT�t LICENSE REQUIltED FEE P£RMl7'# LIC�NSE REQilIRED FEE PERMIT# _<SOsq.R $50 >25,OOOsq.R. $225 _VENDING-FOOD S25 _<25,000 sq.ft. $80 _FROZEN DESSER'I $40 . TOBACCO $55 xn�can1vcE: sts AMOUNTDUE _ $ 13S.00 '•'""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"*•`* AD�STRATION 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 INSi71tANCE , 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 AND OTHER LODGING ESTABLISHIVIENTS TRANSIENT OCCUPANCI': For purposes of the limitations ofMotel or Hotel use,Transiern 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 maurtain a principal place ofresid�ce elsewhere. Transient occupancy shall generally refer to corninuous occupancy of not more than thirty (30) days, and an aggegate 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 whirlpoois which have been closed for the season must be insp�� by the Health DepartmeM prior to opening. Contact the Health Depaztmem to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform aad standard plate coum 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('n days of closing. FOOD SERVICE CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaitmern by Sling 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 or revocation of your Frozen Dessert Permit until the above tetms haue been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval fromtheBoazd ofHeakh OUTDOOR COOHING: Outdoor cooking,preparatioq 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. TT IS YOUR RESPONSIBILiTY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEM$ER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT,ETC.), MUST BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMEN"T. RENOVATIONS MAY REQUT • LAN. DATE: �I� ��' SIGNATURE: � PRINT NAME&TITLE: �Q� 0925/09 Client#: 67096 BASSRIVERP � ACORD.M CERTIFICATE OF LIABILITY INSURANCE ;;;09,2009 PROOUGER THIS CERTIFICATE IS ISSUED AS A MA7'fER OF INFORMATION HUB Intemational New England ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 265 Orleans Road HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Chatham, MA 02650 508 945-0446 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A'. Of10B03COf1 IOSUlBI1C0 Bass River Piva INSURER B: AIM Gerald A Downing Jr INSURER C: 1311 Route 28 � INSURER D: S Yarmouth, MA 02664 wsuaea e COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANV REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER�OCUMENT 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 AN�CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICV EFFECTIVE POLICY EXPIRATON � LTR NSR NPE OF INSURANCE POLIGV NUMBER DATE MM D DATE MM O LIMITS /� GENERALLIABILITY F81U23968 �7/��/O9 �7/0�/�Q EACHOCCIIRRENCE a500000 X COMMERCIAL GENERAL LIABILITV . DAMAGE TO RENTEO $'�OO OOO CLAIMS MA�E � OCCUR MEO EXP(Any one person) E$00� PERSONAL 8 AOV INJURV ESOO OOO X OCP GENERALAGGREGATE S'I OOOOOO GENL AGGREGATE LIMIT APPLIES PER: PROOUCTS-COMP/OP AGG $'I OOO OOO POLICV PE� LOC AOTOMOBILE LIABILITY COMBINE�SINGLE LIMIT � � . �'ANYAUTO . . .. . . .. (EaaccitlenQ .. $... . . ..... .... . ... ... . . ..... . . . . . . .. ._.. .. .. _. .. . . ... . ALLOVJNEDAIITOS � BO�ILV INJUftV $ SCHEDULED AUTOS (Per Oerson) HIRED AUTOS BO�ILV INJURV $ -� NON-OWNEDAUTOS �PeraccitlenQ PROPERTYOAMAGE S (Per accitlem) GARAGELIABILITY AUTOONLY-EAACCIDENT $ . ANVAUTO OTHERTHAN EAACC S AUTO ONLV: qGG $ E%CESSNMBRELLA LIABILITY EACH OCCURRENCE E OCCUR � CLAIMSMADE AGGREGATE S $ � DEOUCTIBLE . $ RETENTION E E B WORKE0.5COMPENSATIONAND VWCGOO9GSZO'IZOO9 O7I'I7IO9 O7I'I7I'IO WCSTATU- OTH- EMPLOYERS'LIABILITY ANV PROPRIETORIPARTNER/EXECUTNE EL EACH ACCIDENT $'IOO�OOO OFFICER/MEMBEREXCLUDED? YES EL.DISEASE-EFEMPLOVEE E�OO�OOO If yes,Oesuibe untler SPECIALPROVISIONSbelow E.L.DISEASE-POLICVLIMIT ESOO�OOO OTHER DE5GRIPTION OF OPERATION51 LOCATIONS I VEHICLES I EXCLUSIONS AOOEO BV ENDORSEMENT/SPEGIAL PROVISIONS '•Workers Comp Information " Proprietors/PartnerslExecutive O�cers/Members Excluded: � GERALD A DOWNING, OWNER � � (See Attached Descriptions) � CERTIPICATE�HOLDER CANCELLATION � �� " SHOULO ANY OF THE ABOVE OESGRI8E0 POLICIES BE CANCELLED 6EFORE THE EXPIRATION Town of Yarmouth UATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL �_ DAVS WRITfEN Board of Health NOTICE TO THE CERTIFICATE HOLOER NAMED TO THE LEFT,BUT FAIIURE TO DO 50 SHALL ��OG M21f1 SS. IMPOSE NO06LIGATION OR LIABILITY OF ANV IONO UPON THE INSURER,ITS AGENTS OR S.Yarmouth, MA 02664 REPRESENTATIVES. AUTHO��RE�TATIV� ACORD 25(2001I08)� of 3 #53188871M318884 RT001 o ACORD CORPORATION 1988