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Home My WebLink AboutApplication and WC . �� TOWN OF YARMOUTH BOARD QF HEA�1'H C�r. PaQ��zS APPLICATION FOR LICEN5E/PERNIIT-2010 �-�-lil3 * Piease complete form and attach all necessary documents by December I S 2009. Failure to do so will result in the return of your applicahon pac tet. NAME OF ESTABLISHMENT: C�Af�T��; M.cll�H s- �L� _Z�C TEL. #�g��' 4,C� LOCATIONADDRESS: �� t �,� !'fia�h S'f_ MAILING ADDRESS: t,�P��A,�H�� ,p-I,�F oaE j OWNER NAME: _ _C��c A�d Me�h� i�v TAX ID (FEIN or SSNI: ��– �-.� �] CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: ��+f.t1 c� F'f/f�n i� y TEL. # ST�� -36y- '7on 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 cunently certified in basic water safety, standard First Aid and Comtnunity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee certifications to this form. The Heakh Department will not use past years' records. You must provide new copies and maintafn a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION IvIANAGERS - 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. l. 2. PERSON IN 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 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# �a q OFFICE USE ONLY LODGING: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSB REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN S55 _CAMP 555 _SWIMM[NGPOOL S80en. _LODGE $55 _TRAILERPARK $105 _WH[RLPOOL $80ea. FOOD SERVICE: LICENSE REQUIl2ED FEE PERMIT# LICENSE REQUIRED F£E PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEA7S $85 _CONTINENTAL S35 NON-PROFIT S30 �>300 SEATS 5160 �(0�fib I I COMMON VIC. �60 �lo�OOl _WHOLESALE S80 RETAIL SERVICE: —RESiD.KITCHEN S80 LICENSE REQUIl2ED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# LiCENSE REQilIRED FEE PERMIT# _<50 sq.8. $50 >25,000 sq.R. 5225 _VENDING-FOOD S25 _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 TTOBACCO S55 NAME CHANGE: S15 AMOUNT DUE _ $ I�'S.o0 aa-o .o0 »*«"•pLEASE TURN OVER AND COMPLETE OTHER 5IDE OF FORM"**"* ADMIlVISTRATION Under Chapter 152, Section 25C, Sabsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pernrit 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 COMI'. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHII�NTS TRANSIENT OCCUPANCI': For purposes of the limitarions 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 demonstrate that they mairnain 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 sha11 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 wlilch 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.PI,EA5E NOTE: People aze NOT allowed to sit m the pool area until the pool has been inspected and opened. POOL WATER TEST'ING: 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 closmg. FOOD SERVICE CATERING POLICY: Anyone who caters witirin the Town of Yarmouth 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. 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 tt►e above terms have been met. OUTSIDE CAFES: Outside cafes(i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board ofFIealth. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishmerrt is prohibited. NOTICE:Pernrits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RET[JRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUII'MENT, ETC.), MU5T BE REPORTED TO AND APPROVED BY TI�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: j I � �l G y SIGNATURE: �.�� 6�1,�� PRINTNAME&TITLE: �� c �wN� i�v i"��s�c�r;/ 09l25l09 �� CERTIFICATE OF LIABILITY INSURANCE I °A'E`M"",°°,""", 10 2009 Paooucea '�,. THIS CERTIPICATE IS ISSUED AS A MATTER OF INFORMATION i MCSh2H Insurance Agency, IIIC. I ONLV AND CONFERS NO RIGHTS UPON THE CERTIFICATE '�,, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND Op '� 749 Main Street� Suit2NH i ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. �' Osterville, Ma. 02655 508-420-9011 I INSURERS AFFORDING COVERAGE ��i NAIC# I wsuaeo Cdptain Parkers Pub� Inc. � iNsuaEan: Great nmerican Insurance Co. �. iNsuaeae�. Associated Industries of Mass J � 668 Main Street iNsuaea c. I I W. Yarmouth� Ma 02673 � irvsuaeao: i 5 8-771-4266 iNsuRea e: COVERAGES ! THE POIICIES OF MSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING i I� ANY RE�UIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR I, I MAV PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES�ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ' � POLICIES.AGGREGATELIMITSSHOWNMAVHAVEBEENREDUCEDBYPAIDCLAIMS. '' I irvsR oo•� POLICY EFFECTNE PO�ICV EXPIRATION � �,�m NsnD� TVpEOFINSIIRANCE I POLICVNUMBER DATEIMMI�O/YYl DATEfMhllDDM/l I LIMITS � ! �. �� GENERAL UABILITV ' � ' �i EACH OCCURRENCE $ S OOO OOO il X COMMERCIALGENEPA�LIABILITV ��"ET��—� I �vaenaises iea o«��ao�ai �s 100 000 I IcuiMSMnoe '�I occua - Meoexa�a,yo�eae,so�� ' s 5 000 ''�. �� p+ �l � PAC3139486 4/5/2009 � 4/5/2010 PERsoNn�snoviwuav a 1 000 000 '�.i ., '� X ; L1G7UO2' Lldb. I GENERAL AGGREGATE $ '2 OOO OOO '�.. � I GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ Q OOO OOO I ��'' I POLICV r- PRP �� I JECT �OC i j 'i. '�,AUTOMOBILELIABILITV � COMBMEDSINGLELIMR � �_�ANVAUTO i � (Eaacciden�) ,$ .' ' ALLOWNEDAUTOS I I, I�— III I I BODILYINJURV I$ I, II �_ SCHEDULEDAUTOS , (Perperwn) , '�, �i '� : HIREDAUTOS '' ' �— I BODI�VINJURV I $ �. � �� NON-OWNEDAUTOS �Peraccldent) I —i I PROPERTV DAMAGE I$ I �. I (Peraccitlenp � , '�, I, �I, I; GARAGELIABILITV I AUTOONLV-EAACCIDENT � $ � ' ��ANVAUTO �� OTHERTHAN �ACC $ —i I i �, I AUTOONLV�. AGG $ I �, �i li EXCESS/UMBRELLA LIABI�ITV EACH OCCURRENCE '$ I � �i OWUR �� CLAIMSMADE �I � � �AGGREGATE j 6 - i '�. ,.—. i $ � li �� j DE�UCTIBLE i ' $ ' '' I AETENTION $ �$ �I '�. �I WORKERSWMPENSATIONAND �ORV IMITS ER I, �, eMP�oveas�uneiuTv y7T{Z8003661012 4/1/09 4/1/10 e.�.�.cr+nccioeNr s 500 OOO I� I ��.qNY PROPqIEfOWPMTNERIEXECUTIVE I B .�,OFFlCEF/MEMBER EYCWOEOi . I E�.DISEASE-EAEMPLOVE $ SOO OOO ' ' "i, Ityes.dexribeunder '' � 500 000 '� SPECIA�PROVISIONS balow EL OISEASE-POLICV LIMIT '$ OTHER I I i �i � ,OESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXC W SIONS AD�ED BV ENDORSEMENT/SPECIAL PROVISIONS � CERTIFICATE HOLDER CANCELLATION SHOULDANVOFTHEABOVEDESCRIBEDPOLIQESBECANCELLE�BEFORETHEEXPIRATION � � Town of Yarmouth � Health Department DATE iHEREOF, THE ISSUING INSURER WILL ENOEAVOF TO MAILl� DAYS WRITTEN ', �� NOTIGE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFI.BUT FAILUHE TO 00 50 SHALL��, i Yarmouth, MA , �,, IMPOSE NO OBLIGATION OR LIABILITV OF ANV KIN�UPON THE WSUREF. ITS AGENTS OR ' FAX: 508—3 9 8-08 3 6 REPRESENTATIVES. �, AUT RI D REPRESENTATNE , I ACORD25(2001/08) � �OO ACORDCOR RATION 1988 �