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Home My WebLink AboutApplication and WC ,_ _. wa�n.w� � . TOWN OF YARMOUTH BOARD OF HEALTH : ' �� APPLICATION FOR LICENSE/PERMITI-2p �� $ �:;;�� ;#� _ �"'' * Please complete form and attach all necessary docu�ire�nt�y�ecen�ber I5. 2015 ! Failure to do so will result in the return of your application pa�cketr ' ESTABLISHMENT NAME: a1ZJr � � arr TAX : - ��", LOCATIONADDRESS: 1313 i��ul�P 2� SDut/� �cs/'�dc�?� //'/9 DL66S� TEL.#: 50d'39d�1/L5 MAILING ADDRESS: E-MAIL ADDRESS: OWNER NANIE: �Cin�!? C' %u � CORPORATION NAME (IF APPLICABLE): W�'�z2�- �, �Nc. MANAGER'S NAME: Kin�9iP iu TEL.#: CjD,�-��''�/.2 �iL�rrGaDD�ss: /3�3 outy � S�ti�� arrna� � �/�- 0� 6f� , 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. -- �.- -- —__ —_ __ _ _ - _ __ 3: .-- -- -- _ . _ _ _ _ _ . Pool operators must list a minimum of two employees cunently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. Z• 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 Tile at your establishment. 1, 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. - —_1. _ - -- ��._�-2.�___ _ ---�_�_� - ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. 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-chokmg 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 # . __ . ___..-. _ _ � L - __. _-..._.--_-..-'_-_ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# B&B $55 CABIN $55 MOTEL $I10 [NN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 TRAILERPARK $105 _WHIRLPOOL $ll0ea. FOOD SERVICE: LICENSE REQU[RED FGE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT li 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 — —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT LtCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<50 sq ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 _FROZEN DESSERT $40 � 1 TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ I 6 O. 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 INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taYes and liens must be paid prior to renewal or issuance of your permits. PLEASE 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 sha11 be limited to the temporary and short term occupancy,ordinarily and customarily associated with mofel 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 inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in 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 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 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 obtamed at the Health Departxnent,or from the Town's website at www.varmouth.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 prior approval from the Boazd of Health. OUTDOOR COOHING: ' 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 3 L IT IS YOUR RESPONSIBILIT'I'TO RETURN , THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ' 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 SITE PLAN. DATE: �I �I �S� SIGNATURE: �-/'�'IYI��' CGJ/(�/ ; � PRINT NAME & TITLE: ��J'//1/..P ��?/G( , �17��-' Rev. 10/01/IS � The Commonwealth ofMassachusetts ,. - . Department of Industrial Accidents Offace of Investigations � I Cangress Street, Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv Business/Organization Name: ��fe r�u�I oR.� �-i�u c rs Address: ��23 �C�ufQ � Ciry/State/Zip: �a,,tt�1 �a Wna ti�- ��} �Phone#: �U� 3�� -2 ��-5 Are yqu an employer? Check the appropriate box: Business Type(required): 1.�I am a employer with � employees(full and/ 5. �Retail or part-time).* 6. ❑ RestaurantlBaz/Eating Establishment r — - - - — -- - ---- _ -- �;�� ec a s�1�-prop3ieeoe ot pa-Ti ners�ip an�have era �, []Office and/or 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 corporation 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]* 11.❑ Health Care 4.❑ We aze a non-profit organizarion, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other . •Any applieant that checks box#1 must also fill out the sec[ion below showing their workers'compensation policy infoimatioa. •*If the coipornte officers have exempted themselves,but the cotporarion has other employees,a workers'compensation policy is cequired aad such an organization should checkbox#1. I am an employer that is providing workers'co ensat/ion insurance for m/�y employ^s Be[ow is the policy informatiom Ins�sance Company Name: m� �fCt�� QdCV1Q��fS �l�f� �71Cdup 1NC Inswer's Address: I � �r'�iS 6� �QVICGVI t�11/� . i L��G1Vl /�1 I ��0 City/State/zip: Policy#or Self-ins.Lic. # � I `� �b"J U� � � �5 Expiration Date: � � Z�'� Attach a copy of the workers' compensation policy declaration page(showing the poticy number an ezpiration date). Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalues of a '- -�e up to ' , . �one-yeazimprisonment;as well as clvTpen�ies m fne form of a�TOP WaItK�lII�EA and a`nne _ -- of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesfigations of the DIA for inswance coverage verification. I do hereby eertify,under the pains and penalties ofperjury that the information provided above is true and correet. Sienature. �� C�� Date: I 1��f�l S Phone#: �� J�� -��-� Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Bnilding Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �'1 WATER-3 OP ID:AD '`��Rp� CERTIFICATE OF LIABILITY INSURANCE onrE�Mruoorcvw� 1 0/2 712 01 5 THIS CERTIFICATE IS ISSUEU AS A MATTER OF INPORMA'TION ONLY ANO CONFERS NO RIOHTS UPON THE CERTIFICATE HOLDER. THIS CER7IFICATE DOE3 NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE pFFdRDED BY 7HE POLICIES BELOW. THIS CERT7FICATE OF INSURANCE DOES NOT CONSTTUTE A CONTRACT BETWEEN THE ISSUING INSURER�S�, pUTHORI2ED REPRESENTA7IVE OR PROOUCER,AND 7HE CERTIFICATE HOIDER. IMPORTANT: If the certiflc�e holder is an AUDITIONAL INSURED, the pollcy�les)must be entlorsed. IT SUBROGA710N IS WAIVED, s�jecl lo Ihe lerms and condilions oi the policy,certain policies may require an endarsement. A statement an this cerfiTica[e does not confer rights fo the certlflcate holtler In Iieu ofsuch endorsement s. � � PRODUCER �E_ WM.F. BorheklnsuranceAgencY PtiorE ""�-��— Fnx �""�--- 311 Plymoutb Street Wc No e.n: ___ (ac r�o7: Halifax,MA02338 E�.tAi� � -� — Todd A.Morse,qC A��g$� INSURER�S)➢FFORDINGCOVERAGE NAICN '_'— —___.._ _ INSURER A:H3110VEf IIiSUI'd110E - —___. . __ — __'_'-- ___' __— INSURED WaterwheelTrustee iNsuRERa:MassachusettsRetailMerchants Kinnie Chiu Waternheel28,Inc INSURERC: — ------ ----- 1323 Rt 28 S INSURER 0: ------ -.__.__. South Yarmouth,MA02664 INSURERE: INSURER F: � �- � COVERAGES- - � - ��C{-f2fIFICATENUN46ER��--- _ _ . . __ ._ _ _ _ ____&EVISIOy U BER: THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTE�BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIO� INDICATED. NONJRHSTANDING ANY REQUIREMENT,TERM OR CONDITION Of ANV CANTRACT OR OTHER DOCUME7VT WfTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLIqES DESCRIeEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMRS SHOWN A7AYHAVE BEEN REOUCED BY PAID CL41MS. INSR LTR NPEOFINSURANCE PDLICYNUNBER MMID01 MMIODIYVYY UMRS GENERRLLIABILITY EACHOCGURRFNCF $ 'I�OOO�O A X COMMERQALGENERAL�IABILITY ODN-9037325-00 ��/20�5 �Q/��/2��6 ��T`� PRemises eaott�R�� s 300,0 CLAIMSNA�]E �OCCUR MEDEXP(AnyonaGerson) $ S�O X 8usinessOwners _ _ I FERsoNn�snovmduRv a 1,000,0 � GENEkALAGGREGATE S Y�OOO�O GEMLkGGRE6NTELIMITMPLIESPER�. PRODlICTS-COMP/OPAGG $ Z�OOO�O .._.______."__— -- $ POLICY jR0- LOC Al1TOMOBILE LL4BILIlY f I.. I � Eaacadenl $ ANY AUTO BODILY INJURY(FerDarson) $ ALLOWNED SCHEDLILEO BODILYINJI�RY(Perec6tlent) $ AUTOS �AUTOS HIRE�AUTOS NON-OWNEO PROPERTY�AMAGE $ � AUTOS PER ACCIpENT _ $ UMBRELLl1LW0 OCCUR F_ACNOCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ �JED RETEPlTIONE $ WOPo(ERSCOMPENSATION X WCSTTTLL OtH- AAO EMPLOYERS'LIA&LITV B nNVPrzoPRiErcR�aRrriER�cunvE Y�N 0140050337715 07/01/2015 01/01l2016 E�.EnpiacaorNT 8 100,0 OPFlC[WMEMBEP.EACIUDE07 � N�A (MantlrtoryinNH) EL.�ISEASE-EAEMPLOVEE $ ��i� Ityes,describe under UESGf21PTI0kOFCPERP.TIONSbelow EL�ISERSE-POLIGVLIMI�' g SOO�OO A BUSINESSOWNERS DN-9037325-00 � 04l0112015 OM01I2018�BUILDING � � �� 260,0 � PROPERTY 197,5 DESCRIPTION OF OPERATION51 LOCATION31 VEHCLES (Attae�RCOR�101,AtlEltlonal Remarke Schatlulq I/more apaea le redulre'Q CERTIFICATE HOLDER CANCELLATION . TOWNOFS SNOULD ANY OF iHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TownofYarmouth TME EXPRA710N DATE 7HEREOF, NO710E WILL BE DEUVERED IN ACCORDANCE WYfM 7XE POLICY PROVISIONS. . 7146 Route 28 South Yarmouth,MA 02664 p�{{pRIZEDREPRESEMATNE Todd A. Morse, CIC �1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD