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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HE L i � G3C�GCO�'IC�DD � � � APPLICATION FOR LICENSE/�I �'� � � , � �' � t 1015 �"'' * Please complete form and attach all necessary doc c¢fiib r IS 2�15. Failure to do so will result in the returri of your�application pac t. HEALTH DEPT. ESTABLISHMENT NAME: T D: `7 LOCATION ADDRESS: Y� TEL.#: MAILING ADDRESS: a� E-MAIL ADDRESS: �\ � Ca � ' OWNER NAME: - �`AdL�� ' CORPORATION NAME APPLICABLE :�Qv2Nc� �'ov� J MANAGER'S NAME: J_�vJ�a��J C� , TEL.#: MAILING ADDRESS: aRTl�ot�'+►L� U1 2� V`n ea6� �' POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool�r s a� �nd attach a co of th� certification to this form.�� P � ) PY 1. ti�vS��C�P f.�JGRCG�� - - _ _ _ 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�0.��C� �jW`a.n�5 2.1�?��ra�P ��G.'Q�l 3?--�• �l�J` P�►.b� 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. i. �.`�; � '�evc►�o� l,N �oc��o�x,� z. T PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i. �_�o-�-��2�t� 2. � ALLERGEN CERTIFICATIONS: All food service establishments are 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. -� � �.10.A� ��.�PJ�ZF�I G 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 C►le at your place of business. 1• '��^�Kt-`C--� �/,�n�S 2. � ��W1 3. 4. RESTAURANT SEATING: TOTAL# �� - —- _ _ -- ---_ [1FFIC_E-�ISL�il�ii,i'-- - - __--- ----— - - - LODGING: ' LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 �INN $55 �?i CAMP $55 SWIMMINGPOOL$IlOea—�(� _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea.�g _�p�e-�� FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ( 0-100 SEATS $125 �(�A�2 CONTtNENTAL $35 NON-PROFIT $30 >100 SEATS $200 �COMMON VIC. $60 �r'j =��DEKITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 _<z5,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAMECFIANGE: $15 � AMOUNTDUE _ $ ��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 WORKF,R'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 f MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe 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, 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 pseadomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarteriy 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 obtained at the Health Department,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.,outdoar seating with waiter/waitress service),must have prior approval from the Board 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 3 L TT IS YOUR RESPONSIBILITY 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 A SITE PL N. � DATE: � � � SIGNATURE: .�.. - PRINT NAME & TITLE: � Reo. 10/01/IS - � jd�� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DDNYYY) iz/la/zois THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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 certificate holder is an ADDITIONAL INSURED,tAe policy�ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the tertns and conditions of the policy,certain policies may require an endorsement. A statement on this certifiwte does not confer rights to the certifiwte holder in lieu of such endorsemenqs). PRODUCER CONTACT MyCh801 EdaP8id8 NAME: L8ML6ilCB C8TZ1II Insurance A(j6RCy PHONE (SOBJ S�SO-�SOO � Np�.(508)5<0-8<26 -MAIL — ""._'_" 230 Jones Road noo2ess:M1chael@lawrencecarlin.com INSUREWg1AFFOR0INGCOVERAGE NAICN Falmouth MA 02540 iNSURERAArbella Protaction 41360 INSUREO INSURERB:H08pltdllt MI1t1181 IRS13I8i1CB CO.LOIl181 EI01196 IIIIl� DBA: P6LRd Consultanta� Zi1C. INSURERC: '277 MdlII SYS92t INSURERD: ROUGB G A INSURERE: YBIIDOuYhpOli MA 02675-0000 INSURERP: COVERAGES CERTIFICATE NUMBERCL15121400932 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 7HE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH 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.IIMITS SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypEOFINSURANCE A � POLICYNUMBER M�MFD�D� MM%Dv� lJM1T5 LTR R COMMERCIAL GENERAL LIABILIT' EACH OCCURRENCE $ 1�000�000 DAMAGETORENTED 100�000 A CLAIMSA�IADE X OCCUR PREMISES Eaoccurtence $ 8500006406 '//3/2015 '//3/2016 MEO EXP(My one person) $ 5�000 � PERSONALBADVINJURY $ 1�000�000 GEN'LAGGREGA7ELIMRAPPIIESPER�. GENERALAGGREGATE $ 2,000�000 POLICV❑ PR� � LOC PRODUCTS-COMP/OPAGG $ 2.000�000 X JECT OTHER: $ AUTOMO&LE LIA&LIT' C MBINE�SINGIE LIMIT $ � Ea accident /WVAUTO I BODILVINJURY(Perperson) $ _ ALL OWNED SCHEDULED BODILV INJURV(Peremitlenq $ A�OS NON-0WNEU I PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peraccident 5 UMBRELLALIAB pCCUR EACHOCWRRENCE $ EXCESS LIAB CIAIMSIAAUE AGGREGATE $ DED RE7ENTION$ 5 WORKERSCAMPENSAiION PER OTH- ANDEYPLOVERS'LIABILIT/ Y�N STATUTE ER ANY PROPRIETOR/PARTNER/E%ECUTIVE ❑ N�A ELEACHACCIOENT $ OFFICERRAEMBER E%CLUDEDT (ManCatory in NH) E.L.OISEASE-EA EMPLOVE $ Myas Oescnbe uMer DESCRIPTION OF OPERATIONS balo.v EL.DISEASE-POLICV LIMIT $ 8 LIQUOR LIABILITY 00050402LL ]/3/2015 '!/3/2016 OCCURENCE $500�000 AGGREGATE $500,000 DE5CRIPTION OF OPERATON51 LOCATONS/VENICLES (ACORD 707,Atltlitlonal Remarks Sc�etlule,may be attachetl if more apaca is requiretl� CERTIFICATE HOLDER CANCELLATION (508)362-Q348 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE T0V7I1 of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 26 ACCORDANCE WITH THE POLICY PROVISIONS. 3outh Yarmouth, MA 02664 AUTHORIZED REVRESENTpiIVE David Lawrence/MEDWAR �—"�� +�.,...� �O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2074/01) The ACORD name and logo are registered marks of ACORD INS025r>mnm� Additional Named Insureds Other Named Insureds Perna Consultants, Inc. Doing Business As OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC CIieM#:53645p 2COLONWLHO ACORD,,, CERTIFICATE OF LIABILITY INSURANCE °"'�""'°°""'"' S/71/2015 iH13 CERIIFlCATE►8 IggUEp qg q MpTTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TNE CER7IFICAiE HOLpER.iH13 GER7IFlCATE DOES 110T AFFlRMAiNELY OR NECaAT1VELY AMEND,EXTEND OR ALTER THE COVERAGE AFFOImED BY THE POLICIES BELOW.THIS CERTIFlCATE OF�NSURpNCE DOES NOT CONSTI7UTE A CONTRACT BE7WEEN THE ISSUING INSURER(Sh AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFlCATE HOLpER. INPORTqNT:if the certl�ryeats holdar is an ADDRWNAL INSURED.tl�e pollry(i�)must be endo�sad.lf SUBROGATION IS WAIVED.subjeet to Me Osrtns a�M condltiora M the Pc�kY.certain poNcles rt�Y raquire an endorsemeM.A statameM on thb certlflcata does trot cordar righffi to the cartlflcaEe holder in Ileu of sueh endorsemeM(s). vaouucae Dowling&O'Neil "^�' Insuronce Agency � �508 775-1620 ,b: 5pg7781218 9731yannough Rd., PO Box 1990 Hyannia.MA 02601 ms��usl�roHowccweinc� wucs �u� aaunaen:Associated Employers insurence Pema ConsukaMs,lnc.OIB/A ��"B` Colonial Ho�e Inn �11Ret�' 277 Main Route 6q wsu�eo: Yarmouth Port,MA 02675 '��"E: MfBURHt F: COVERAGES CER71RCA1E NUMBER: REVISION NUMBER THIS IS TO CERTIFY THqT THE POLIGES OF INSURANCE LIS7ED BELOW HAVE BEEN ISSUED TO THE INSURED NqMED ABOVE FOR THE POLICV PERIpp INDICATED. NO7WITHST/WDING ANV REpUIRE1�NT, TERM pR COND1770NOF ANV CANTRqC7qt O7HER DOCUMEM WRH RESPEC7 TO WHICH THIS CERTiFICA7E MqY BE IS3UED Oft Mqy pERTAIN, TNE INSUR/WCE AFFORDED BY THE POLICIES DESCRIBED HQ2EIN IS SUBJECT TO ALL 7HE TERMS, p��DC0.�3�ONS !WD CONDt710NS OF SUCH POIICIES. LIMRS SHOWN MqY HAVE BEEN REDUCED BY PAID CLNMS. L7R 7YPEOFRlSUMNCE � WVO POLICYNUIOFR � ��Y �$ G@�tAL W1BR7fY EACHOCCUR(�RE�IM:E $ COMMERCWL6ENERALLIP6IL(fY Ee �nce E CWMS�MFUE ❑OCCUR MEDEXP qrepaam� g PER80NALdADVINJVRY E GENERALA6GREWTE y OEML AO(iREGA1E IJMRAPPLIES PER PRODUCTS-COMP(pPAGG S �� LOC S �� MBINED SINGLE LIMR ANYAvfo BODILVIwURY(Pornaeon) E ALLOWNED SCHEDULED AVTOS AlRQS BODILVIWUR/IPerectlEen�) $ HIREDAIRQ4 ��E� AUI'OS ��DAMAGE $ IUB�Ltw u�B OCCUa E encHoecuarsenee E EXCE$8 LIRB Cl.A1kSMpDE AGGREGFTE y � RETE1lIWNS A MIORIffRS COYPB18AilON S armew�ora�•uneiurr WMZ80080035742075A 01/2015 04/01/201� X `"�ST^T�' °TM- u+r raoPwerowrarzrtaewocEcurne r�x E5�000 aFFICEWMEABERE%G-U�ED? � N/A E.LEACHACGpF1J7' 1�b a� �S�E��ERRTIONS bebw EL DISEASE-FA ETIPLOVEE $SOO� E.LDISFA4E-POLICYLIMIT E.�OIW GESCRPfId10F OPEItA710NS/LOCATION$/VEFYCLE6(ACxh NCORD 107.Atltlltlonal RanMs StlrGu141Finae Wxs is�Wu4etl) ��surance coverage is Bmlted to Uie terms,condtiions,e�cdusions,other limitations and endorsaments, Nothing�Mained in the cxBficats pf insurance shall be deemed W ryave altered,vwdived.pr exterMed the co�er�e P►evided by Ure policy provisions. CERTIFlCATE HOLDER CANCELLATION Pema Consukants Inc.DBA ��o^M"oF TMe nsov�o�scweEo noue�s eE ca�c�o e�ore� Colonial Ha�e Inn TME °O'�R^T�+ °ATE TME�, Np71� WILL BE OELIVEREp 1N wccoRonnce wm� nie aaicr anowsaNs. 277 Main Route BA Yarmoutlipon.MA 02675 nunww�o rtEvrs�ae�r�rne �1988-2010 ACORD CORPORA710N.All rights r�arved. ACORD 25(2010/05) 1 oP 7 The ACORD nartie and bgo are registered marks of ACORD �S1S0861lM750860 CBD