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Home My WebLink AboutApplication and WC a��,�y � " a TOWN OF YARMOUTH BOARD H v �: �� ' APPLICATION FOR LICENSE/PE ��, � .. -- � � ... , * Please complete form and attach all necessary +cu s y ecem r 1 . D�� Failure to do so will result in the return of your applicat�on pac ESTABLISHMENT NAME: C C✓' U TAX ID• �— LOCATIONADDRESS: ��c Co s�r TEL.#: G'.3 - S' OD MAILING ADDRESS: ,.r w (o y OWNER NAME: ✓�.� i +S 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 certification to this form. 1. 2, Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary 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 file at your place of business. l. 2. 3. 4. 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 Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. ��✓-►-� �A,�3 2. /n��A� �T-�,��.�H„ / � PERSON IN CN�1RrE: Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation. 1. /y�i9'n �,4v(3 2. HEIMLICH CERTIFICATIONS: All food service establishmenu with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all tunes. 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# OF'FICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP y55 _SWIMM1Ni.;YfJOi. $8Cxa _LODGE $55 _TRAILER pARK $105 _WHIRLPOOL $80ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100SEATS $85 ��L3O _CON1'INENTAL $35 _NON-PROFIT $30 _>I00 SEATS $160 1COMMON VIC. $60 �� —D� _W[-IpLESqLE $gp RETAII.SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE pF,RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _d0 sq.fr. $50 _>25,000 sq.ft. $225 l� _VENDING-FOOD $25 _Q5,000 sq.ft. $80 1FROZEN DESSERT $40 ��a'V(� _TOBACCO $95 NAME CHANGE: $IS AMOUNT DUE _ $ I 85.00 x»4rspLEASE TURN OVER AND COMPLETE OTFIER SIDE OF FORM'�'*+'* ADMIlVISTRATION • , Under Chapter 152,Section 25C, Subsection 6,the Town of Yarmouth is now required to holdissu�, e 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 INSUItANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVPI' SIGNED AND ATTACHED Town of Yazmouth taxes and liens must be paid prior to renewal or issuance of your permits. PI,EASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHN:K LUDGIN�ESTABLLSHMI;N1'S 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 priar to opening. Contact the Health Department to schedule the inspection three(3)days pnor to opening.PL.EASE 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 standard plate wunt 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 mnst 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 Yarrnouth must n�tify the Yazmouth 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 Deparunent,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: - (1ut;;de ea��s�e.,s�t�c�r�atir.g wir.t�waater/waitrPss se:vicPi,mast?:zv��ier a�eva�frcr.:ths B^ard of Heal+.h. 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 January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. ALL 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 REQUIRE A STI'E PLAN. DATE: /I��} I7f�� SIGNATURE: ��G�✓' PRINT NAME &TITLE: Q'�✓�✓� N� - �'�� Rev. 10/25/11 Dater 11/29/2011 Tima� ll�la AM To� 15083987365 AOQera 8 Gtay Ins. PaQe� 002 Ciierd#:46785 CCCRE ACORD.� CERTIFICATE OF LIABILITY INSURANCE °;;;29�°„"" THIS CERi1FICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIPICATE DOES NOT AFFIRMATNELY OR NEGATNELY ANEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POIICIES BELOW.TNIS CERT1flCATE OF INSURANCE DOES NOT CONSTfTUTE A CONTRACT BE7WEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTA7IVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORT : the aertKeate ho er is an AD N L NSURED,the p Icy(ies)must be e orsed.lF SUBROGATIO W ED,subjeet to the terms aml conditions of the policy,eertain polieies may require an endorsement.A statement on this eertifieate doea not confer rigMs to the eeR�eate holder in lieu of sueh endorsement(s). YRO00� �, Margaret Young Rogers 8 Gray Ins.So. Dennis �� 508-760�602 508 258-2129 434 ROU�B�34 No Bs: __, (M,No): P.O. Box 1601 nooness: deleode�rogersgrey.aom cuaroMert ro s: South Dennis, MA Q2660-1801 rsu s nFsanarrc crnrennc� wucs irrsursEo ��RA;CNAlContinarkal Casualty Compan Cape Cod Creamery,LLC iNsu�ne:Natianaf Fire Insurance Co.of 5 Theater Colony Way —• SouthYarmouth,MA 02664 ��1t°` wsurserto: � MAURERE: .. RISURER F: COVERAGES CER7IFICATE NUMBER: REVISION NUMBER: 7HIS IS TO CERTIFV THA77FIE POLICIES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE BJSURE�NAMED ABOVE FOR T1�POLICY PERIOD INDICATED.NO7WRHSTANDMG ANV RE�U6iEMENT,TERM OR CONDRION OFANY CONTRACT OR O7HER DOCUMENT WRH RESPECT 70 WHICH 7HIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BV THE POLICIES DESCR6ED HEREIN IS SUBJELT TO ALL THE TERMS. EXCLUSIONS AND CONDRIONS OF Sl1CH POLIG�S.LIMI75 SHOWN MAV HAVE BEEN REDUCED BY PAID CLAMS. TYPE OF WSURANCE PO{!CY NUMBER � 11MIf5 A �� B2077173822 5/01/21N 1 05101207 EacH occur+Rerce E1 000 000 X COMMERCIAL GENERAL LIABILI7V o rtmm a300 000 cwMs-naoE �X occu�e . n�o�r o�a�o�� a70 000 . aFns�uaaoviNduRv a70000Q0 OENERALAGGIffGA7E SZ�OOO�OOO GEN'LAGGREGATELIMITPPPLIESPER: RtOOtICB-COMP/WAGG {YOOOOOO POLICY � LOC E B ��WB�Y YO9SI9OYHB S/O�/ZO�� OS/O�IZO� COM8INEDSINCLELIMIT ANV AUTO (Ea eo^1tleM) a� OOO OOO BODILVINJURY(Perperaon) $ ALL OW�D AUi05 BODILV kJJURV(Pe�e¢tleM) § X SCHEOULEDAlR05 pRppE{llypqMqGE X HIqEDALROS (PerectlEenq S X NW!-ONNEONUTOS S a B ��W� X accua B2097307387 5f01l2017 05/01201 �.cr+occuaaerrce Ei �0000 Excsss uns cuius-i,w� nccr�cn� 51 000 006 oeoucne� y X rt�Nrro 10000 a p worsKersscan�reusnnorr WC2077773879 5/07/201105101/207 X WcsraTu- oni- umexe�orens•une�m riN �i�Ow�m�s��i�oi��❑N wa ELEACHACQOENT s500000 (��daYM�) E.L.DISEASE-EAEMPLOVEE ESOO�OOO H tleevlOeuMer SCRIP�ION OF OPE TIO bw � E.L OISFASE-POLICY LIMIT SOO OOO OESCRIPf10N OF OPERATqNS/LOCpTqNS/VEXICLES(Nqch ACORO 707,Atld�bnel lbmvks SMedub,lF mon apew b rputW) �;'�'`/ 2 � 2�� CERTiFICATE HOLDER CANCELLATION � TOWII Of YBfrt10U[h,HealYh DePt gf10ULD ANV OF 7HE ABOYE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Malfl StfBBt, Route 2$ THE EXPIqATION DATE THEREOF,NOTICE WILL BE DELNEI�D IN ACGORDANCE WITN THE POLICV PItOViSIONS. South Yarmouth,MA 02664 nurxat�o�rrseserrrnrne i �19 -2009 ACORD CORPORATION.All righffi reserved. ACORD 25(2009/09) � pf� The ACORD nxne and bgo are registered marlcs of ACORD #ST4483/M67947 M�,