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Home My WebLink AboutApplication and WC� ' � � �� TOWN OF YARMOUTH BOARD OF HEALTH ' � APPLICATION FOR LICENSE/PERMIT- 0��t _ * Please complete form and attach all necessary� ents 6y Dece ber I S �UIZ. - ' Failure to do so will result in the return of your application p cket�EB � 4 Z��3 I ESTABLISHMENT NAM : , ""(�p NEALT�� pr-D-f. LOCATION ADDRESS: c v TEL.#. �� l - ZU II� MAILING ADDRE�$: SF1dvlli� OWNER NAME: � ��h 21 '�I� 'cR CORPORATION NAM�IF APPLIC E : U. f�'U �Ll-- MANAGER'S NAME: �t2�CA.) �V�c,�{ EL. : ��/-�o�-S i 5 I MAILING ADDRESS: �-�.'L a mrrnd �r�tl��.� �ma,.1 C�-rn� v POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Poo Operator(s) an ch a copy of the certification to this form. 1. '-Q 2. Pool e ors 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 certifications to this form. The Health Deparhnent will not use past years' records. You must provide new copie nd maintain a file at your place of business. r 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: Ail 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. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. i. � ,,ria U�� z. �e��a 11� �c,l�k ?ERSON IN CHARUE: Each food establishment must have at least one Person In t;hazge (PIC) on site during hours of operation. 1. �['a✓ A � ��ttY� 2. ��1 .t� ��l��C� HEIMLICH CERTIFICATIONS: All food service estabiishments 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. i.�ac , uld�cav�k 2. �arN W�� 3.�� 4. RESTAURANT SEATING: TOTAL# I� c� OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICEYSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 _MOTEL $55 _INN $55 _CAMP $55 _SWIMMINGPOOL $SOea. ', _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $SOea. __ � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRF,D FEE PERMIT N � 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 / >I00 SEATS $160 �COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# . _<50 sq.ft. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 � rranzE c�aNCE: �is AMOITNT DUE _ $ 0��0.or. **""*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 INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES� NO MOTELS AND OTHER LODGING ESTABLISAMENTS 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 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 OPENING: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 inspecrion three(3)days prior to opening. PLEASE NOTE: People aze NOT allowed to srt m the pool azea 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 ar 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 Yarmouth must notify the Yazmouth Health Deparhnent 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: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have priar approval from the Boazd of Health. OUTDOOR COOHING: 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 RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2012. 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 IRE PLAN: -, DATE: I�Q{7, I 3 SIGNtATURE: � `�-A, . V�✓; �,t�-h �i'1�1 PRINT NAME & TITLE: c�i Rev. 10/09/12 f + . r� The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Le�iblv Business/Organization Name'�� \ hCtiJV1('�YIC.� �a� —�.iA \<U ' A� Address: � � �.�t�� '�r` ' �y'�S City/State/Zip: ( C�� k GZPhone#:�Sb�G� �0��{—�(�tZU Are ou an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with�employees(full and/ 5. ❑ Retail or part-time).* 6. �RestaurantBadEating Establishment 2.❑ I am a sole proprietor or parhiership and have no 7. �Office andlor Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We aze a corpontion and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. (No workers' comp. insurance required]* 4.❑ We aze a non-profit organization,stafFed by volunteers, 11.❑ Health Caze with no employees. [No workers' comp.insurance req.] 12.❑ Other *My applicant that checks boz#1 must also fill out the section below showing their workers'compensation policy infotmation. *'If the corpomte officers have exempted themselves,but the corpomtion has other employees,a workers'compensation policy is required and such an organiTation should check box#1. I am an employer that is provfd ng wor cers'compensa o`n, in'surance jor emplo ees. Be[ow is the policy information Insurance Company Name: '�`'�'Ci�.�l�'�a �VTU� � �1/�7'1 ��U✓CI'1 C f` Insurer's Address: � ^��lQ�f �CaJ�{.� City/State/Zip: �V�C�'(� 1 � 1� �.�`�� Policy#or Self-ins.Lic.# �1 C' �4��-y�C"1L Expiration Date: �"�I 3�,'��'�3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). ' Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalries of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civii penalties in the form of a STOP WORK ORDER and a Sne of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,u�er the pains and pena[ties of perjury that the information provided ove is true and conect Si ature: �- � Date: R� � Phone#: � �� — �' �-� -�.7�1�i1 Official use only. Do not write in this area,to be comp[eted by city or town o,fJSciaL City or Town: 11 LM M[kTtT4 Permit/License# Iss ' u o ' cle one): 1. oard of Healt6 .Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: �@-3�i'8—aa31 �( �Z�{� .y..�.�s.go�ia�a �� CERTIFICATE OF LIABILITY INSURANCE Zi$i2o 3"""' THIS CERTIFICATE IS ISSUED AS A MATfER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIPICATE H04DER. THIS � �CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNE�Y AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES 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(les)must be endo�sed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,eertain policies may require an endo,sement A sfatement on thls certificate dces not confer rights to the certiflcate holder in lieu of such endo�semerM�s). PRODUCER �MEA BO]Tt.OII III9IIL8I1CB BOIR1tOII Insuranee P.CJ6IICy P��E . (781)449-6766 F� .(981)aE9-a269 72 River Park Street Eoaa � INSURE AFFORDING COVERAGE NAIC R Needham 2�+ 02494 INSURERA:H03 itali Mutual INSURED msuaeae:Hartford Insurance The Diamond Food Service Group, LLC, DBA: INSURERC: The Diamond in the Rough INSURERD: 81 King Circuit INSURERE: Yarmouth ort I� 02675 INSURERF: COVERACaES CERTIFICATE NUMBER�Bter 12 13 - REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTMTHSTAND�NG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypEOFINSURANGE pp�JCVNUMBER MM�O� M��P UM� LTR GENERAL LIABIL�TY � EACH OCCURRENCE $ S�OOO�OOO R COMMEftCIAL GENERAL LIABILfTV PREMISE Ee occurtence S lOO�OOO A CLAIMS�IADE � OCCUR 0068740GL 2/31/2012 2/31/2013 ME�EXP(Arry one person) $ 5�000 PERSONAL 8 ADV INJURV $ 1�OOO�OOO GENERAL AGGREGATE $ Z�OOO�OOO GEN'L AGCaREGATE LIMIT APPlIES PER: PRO�UCTS-COMP/OP AGG $ Z�OOO�OOO R POLICY PR� LOC $ AUTOMO&LE LIABILITY MBINED SIN LE LIMR Ee ecriEerrt �.A�Q BODILY INJURV(Perparson) $ ALLOWNED SCHEDULED BODILYINJURY(Peraccitlerrt) $ AUTOS NON-0WNED PROPFRTYOAMpGE $ HIREDAUTOS AUTOS Peractltlent S UMBRELLAIJAB OCCUR EACHOCCUftftENCE $ EXCESSLIAB CWMSi�7ADE AGGREGATE S DE� RETENTION$ S WORKERSCOMPENSA710N X WCSTATU- OTtf AND EMPLOYERS'LJABILI7Y � ANVPROPRIETOR/PARTNERIEXECUTIVEY�N BWECC7.B843 1/31/2013 1/31/2014 E.LEACHACCIDENT $ 100 0�0 OFFICER/MEMBEREXCLUDEO? � � N�A 8 (Mantlatory in NH) E.L.DISEASE-EA EMPLOVE $ 100 000 Hye8 desdibe untler DESCRIPTION OF OPERN710NS babw E.L.DISEASE-POIICV LIMR $ SOO OOO A Liquos Liability 0068740LL 2/31/2012 2/31/2013 g�,ppp,ppp� . S2,o0o.0a0 DESCRIP'fION OF OPERATONS/IACA710N5/VENICLES(AMaeh AfARD t07,AdLiHmal Rema�ks SeheEul0.M mole space ie required) The Ringa Way Truat, The %ings Way Condominivm Truat and The Dart�outh Group (managing agent) are added as additional insured on the General LiaUility and Liquor Liability coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIE$BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Dartmouth Group, The Rings Way ACCORDANCE WITH THE POLICY PROVISIONS. Condominiwn Trust, The fCings Way Trust 64 Kings Circuit AU7HORI�DREPRESENTATVE Yaxmouthport, A�. 02675 3 Denneno CISR/Sm A"'"'�"`-�" 3`-^-"�"'� . ACORD 25(2070/05) �1988-2010 ACORD CORPORATION. All righffi reserved. INS02.5 mm�ns�m T6e AC(1R�1 namn ond Innn aro ron:cfnro.l ma.4a nf A!`l1R�l