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Home My WebLink AboutApplication and WC Lv�'s • . TOWN OF YARMOUTH BOARD OF HEALTH Q[�(y[�pb[�po �� APPLICATION FOR LICENSE/PERMLII�T -��1,�� 'S '"'' * Please complete form and attach all necessary doc s� b�� 12�i� Failure to do so will resulY in the return:of y�ar a�pYcatron cket. HEALTH DEPT. ESTABLISHMENT NAME: L�.� S Ll QVar25 l/Y . T ID: LOCATION ADDRESS: 'J � � {M I�-!/� 5T �CJII%f� o��r LcI.�II��/Y�TEL.#: �h`OS'77�-J�000 MAILING ADDRESS: .`j�;, m e. E-MAIL ADDRESS: ��r�n£'�Y1�v�G�l c: Cp Wi.c°a.S�. r'�T OWNER NAME: ArQ � � CORPORATIONNAME (IFAPPLICABLE): G-/./K�-S tQ,v02$, !�C MANAGER'SNAME: C✓a� �OQ.VPS TEL.#: - •5�00 Ma1r.n•rGaDD�ss: ��R� N �F�P Lnl. u�.V�4�moc��, m�A 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. — — - _ _-- L - _ _ _ 2 Pool operators must list a minimum of two employees currently 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. 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. 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-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 tile at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# — — -- ------ --�1F&T��ircF ntvi y_ _ -_ _ _ LODGING: �� LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$IlOea. LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — � —RESfD.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE RMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# �<50 sq.ft. � $50 ��fp. >25,000 sq.ft. �� $285 VENDING-FOOD� $25 � _<25,OOOsq.ft. $I50 � —FROZENDESSERT $40 =TOBACCO $I10 —OOS NAME CHANGE: $15 AMOUNT DUE _ $ 1�O.OO ****•PLEASE TURN OVER AND COMPLETE OTHER S[DE 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 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 ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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, sha11 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 aze 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 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 t�e - Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yannouth 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,or from the Town's website at www.yazmouth.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 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 RESPONSIBILIT'Y 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 REQU A SITE PLAN. ' DATE: ll `�D I� SIGNATURE: � /(� � PRINTNAME& TITLE: �1��I�UI` /�� (.t l�� i Y�P_<SfCIe�-r l�" Rev. 10/Ol/15 � �� The Commonwealth ofMassachusetts Department of Industrial Accidents O�ce of Investigations I Congress Street, Suite 100 Boston, MA 02I14-20I7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print LeEiblv Business/Organization Name:Lukes Liquors, Inc. Address:511 Route 28 City/State/Zip:w• Yarmouth, MA 02673 Phone #:508-775-5000 Are you an employer?Check the appropriate bos: Business Type(required): 1.❑✓ I am a employer with �$ employees (FuII and/ 5. Q✓ Retail or part-time).• 6. ❑ RestauranUBar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7, � p�ce 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 are a corporation and its officers have exercised 9. ❑ Entertainment their right of exempUon per c. 152, §1(4), and we have �0.❑ Manufacturing no employees. [No workers' comp. insurance required]* �� Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 mus[also fill out the section below showing[heir workers'compensafion policy informafion. •*If[he corpora[e officers have exempted themselves,bu[[he wrpora[ion has other employees,a workers'compensation policy is required and such an organization should check box N l. I am an employer that is providing workers'compensation insurance jor my emp[oyees. Below is the po[icy information. Insurance Company Name:Cove Risk Services/MA Retail Merchants WC Group Insurer's Address:P• �• Box 859222-9222 City/State/Zip: Braintree, MA 02185 Policy#or Self-ins. Lic. #0140010598 Expiration Date:12/31/2016 Attach a copy of the workers' compensation policy declaration page(showiug the policy number and espiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, der the pains and 'es ofperjury that the information provided above is true and correct. Sienature: � Date:11/20/2015 Phone#:508-775-2979 Officia!use only. Do not wrete in this area,to be completed by ciry or town officiaL City or Town: PermiULicense# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia /+�.��A LUKEL-7 OP ID:KM ' AL.�RL/� . . ' . OATE�MMIobIYYYY) , ,�,.�- CERTIFICATE OF LIABILITY INSURANCE ,vos�zo+s �:. �TH15 CERT1FtCATE IS JSSUED AS q MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOCDER.TNIS - . CERTIFICATE�OOES NOT AFFlRMAIiVELY pR NEGATIVEIY AMBND, EXTEND OR AL7ER THE.COVERAGE AFFORDED BY THE POLICIES�� .- BEI.OW:. THIS•CERTIFlGATE. OF IN$URANCE DOES NOT CONSTITU7E A CONTRAC7 eEfWEEN THE ISSUING INSURER(S); AUTHORIZED � � -REPRESEN7A7NE OR BRODUCER,ANP TNE CERTIFICATE HOLDER. � � - - � � � � �- --�IMpORTANT: If tlie oertlfleate holder Is an ADDITIONAL INSURED,the�polioypes)must bs endorsed. If SUBROGATION IS WAIVED,subJectlo�� - . �. �ths terms and ConQitioris oP ihe policy;certain policies may require an endoraement� A statement on thfs certiHcate tloes rrot coMeY rights to the �cerllfleate hdder in lieu.of such ootlorseme s. - � � �- . - PROWCER. � .. . . . . . WM.P.Borliek I�4ranee Aganty . . . � E. -7' -�-�31d PlymOuth SNH¢t� � . � � � w �t• y(n�.Nm: . . Hafffax.�MA07338 � . .. . � � ess: � . .�..scottccasagrande � . . . � . . msursewsluwnomcwveAaae r+aca . � ' � � � ixeunErtn:Saf insurence 39434 rt u�suneo 4UfEE$LIQUORS,INC.,�'fAL rosuaene:Hos itali Mu�ai 20 Spdnger Lane ��;(y�achusetts Retail Merahants� West Yeimouth;Md 02673 .. . .� nisu�no:_ � .� � . �� - � � - rc�sux�n rs: � . . � -.. - ' � � ' ' ' ._ .._ . . ' �.. p, ' . _. . ' � . . �"COVEFAGES�- � � � 'CERTIFIGATE NUM6ER:. � � � R SION NUMBER: ' � � THIS IS.70�GERT'IFV 7HAT THE P011CIES OF IN$URAfdC'.E LI$YED�BELOYV HAVE BEEl4��SUEb Tq 7HE INSURED NPiMED A80VE FOR TFIE P041CY PFRI00 ��!NDIEAT�D.,�NOhMTHSTAN0ING ANY REQUIREMENT,�TERM OR CANpITION OF ANY CQNTR4CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI,� CER7'IFICAIE MAY B�13SUE��OR MAY PER7AIN. THE INSURNNCE AFFORDED BY THE POUCIES�DESCRIBED HEREIN IS SU&IEC7 70 AI,L THE TERMS, . EXIX.USIONS dNb�COt�IT10N6 OF SUCH PDUCIES.LIMITS SHOWN MAY MAVE BEEN REDUCED BY PAID CLAIMS. � wsa � . 'rVasoFmsuRqtecE pbucvriuxeElt umo � F . u � uwTs .� . a�uae¢m � � � � . . . encNoccuwe�Nce � � s � 1,Oo0,00 � A X� 'COb@AERCW:GENERFLLWBILITY BMA0018774 � � OSH3/2074 OSh3/2015 R 1 E'� Eaom�men �S ��,� CIAMASfdA�E �OCCUR .. � . ' . . . MEDEXP(MYorep�am) $ 7OaOO . ' . . . PERSONAL$ADYINJURV E 1�0OO.�U - � � � - - 6ENERALAGGREGATE S Z�OOO�OO GENLAGGREGAT�LIMRAPPLIE8P2R: - , , .. . - .' PRODUCTS-CMa+IOFAGO $ , Y�OOD. . �� POLICV . �PR LOC - ' y ' ' � AUiOM4&LE LNBILNY� . . ' � - OMB N SINGLE LIMR ' �e �� qM.�p . . � ..' . . . . . � B�DILYINJURV(per�penon) 5 .. �0�$qFA . ��ULED . � . BOD�LV IN.IURY(PerxcitleM) S '. . . HIREDAUi05 .pN�J1� ' . . PERACG 8 . . . . - . . ' . . . . . $ . . . . x UNN�iEIIA W1B ' 'X� OCCUR � . - EACH OCCURRENCE S . $sOOO.00 A �C�� CWMS�MOE U00001311 . . .05/�91Z0�4 OS/13/2015 p�qE�qTE S 3.��OD � OBD X N 'IUOOO § WDRNEW3COYPEx6�7Mx � � .. . . S7ATU- O7H- . AHD&YROY4R8'W18�lITY . . C a,rroPrsopRieior+mnntrae�cuhYerrw 0140070�98 07/07/2Q74 Q1/07/2016 E.GE0.CHACCIPEN'� 8 �, � � .OpFlCERMElEBER EXGLUDED7� � N/A ' . . � - (W!b?I4rymNN4. � � EA.DI8EA8E-EwEq9rioYEE E � 500,0 .M QNdI0Buldef . . ' . asnaoW � � e.i.oBeas�-raicwuMR .a � 60Q.00 .� �� LIGlUOR ElABILITY 4qOBdB42LL � - � �6&95/2074 05H3/2p16 PEft OGC � �7,000.0 � . -. . � . . � � AGGREGATE � . . - 2.000>00 _ oisCwononoFeinFianows/Locniww;�vel#cLe.itAps�nneonotGbaeereo�alnamaAresenwxMnmonaMroproqukeery . . - . COV&RED LCN.ATION: 531 I�Ilf 3TRE8T�� 6 20 SPRIN6RR SAN6.� roPEST YARMQUTH, D7A � . 02673 - � - � � � � - CE TIFICATEH �LDER� - C NC LLATION � � � SHOULD ANY OF THE ABOVE UESCRIBED POLICIE$BE CANCBI.LED BEFORE TOWN OF WEST YARMQUTH. r� E%PIRATION DA7E THEREOF, HOIICE IMLL BE UELIVERED IN - - ACCURDRNCE WI7fi TNE POLICY PROVISIONS. WEST YARMOUTH;MA 02673 . . �. � � MITHORIZEO REPRESENTAINE - ' - . � . .. Scott C Casagrande � � � - . . � � � � � � � . . 6+1988-201U ACORD CO PORATION. NI rights reservatl: � ACORD 25(2610/OS) � � - 7he ACOaD name and loQo are registered marks of ACORD . - - �