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Home My WebLink AboutApplication and WCI � .i --57YF7ioN=A�'.-�Corov . I � � TOWN OF YARMOUTH BOARD_. T�-�I T -. �� APPLICATION FOR LICENSE/P��iyII �� '' � � ?�15 '"' * Please complete form and attach all necessar��cioc exit9 b3� rrem r 1 i n��,T ' Failure to do so will result in the return of your application packe . =- ESTABLISHMENTNAME: `,i1�q-4;nm Y�r2_ Ln,vorn�e.,,cP TAXID: LOCATION ADDRESS: li5`1 �s}�tiom arve. S�da�rnauu�-G� f`nR .�26E11 TEL#� SoR- 39 g=�S'cs'O MAILING ADDRESS: � Pai�a;cxs L'�c.u . 4'v�sestdQ�p� m�Aw .o�F,u4 E-MAILADDRESS: 1��^�.�,-��i'—�� Vi S�CiL �IZI�1E� CYl LICi.Inbb Ln,�,� OWNER NAME: V�"ghc_.�. Shu k i� CORPORATION NAME (IF APPLICABLE): T-1'ee�n Grrwoa-�.d;an MANAGER'SNAME: �I in-li Shultl TEL.#: So$•52U-'�"'�u4 MAILING ADDRESS: 1 Da+�„cx s �.t74 yi FeaP S+dq„Lo, YYrn� _n�, 4 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 currently certified in standard First Aid and Community Cazdiopulmonary Resuscitation (CPR), having one certified employee on premises at a11 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 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. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: Afl 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 Healt6 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 file at your place of business. 1. 2, 3• 4. RESTAURANT SEATING: TOTAL# - - --_ _- - -- — . _ - LODGING: LICENSE REQUtRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 _INN $55 —CAMP $55 SWIMMINGPOOL$IlOea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-IOOSEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 � —RESID.KITCHEN $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 �<25,000 sq.ft. $I50 ��Z =FROZEN DESSERT $40 �TOBACCO � $1 t0 ��7 fO ,. NAMECHANGE: $]5 AMOUNTDUE _ $ 260 .oQ �� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I , __ , 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 V� 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: I YES �� NO i MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and customazily 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 � i 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 aze 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 standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereaftet 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: I Anyone who caters within the Town of Yarmouth must notify the Yarmouth 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 thereafrer,with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen DesseR 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 Board of Health. II 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 I THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2015. I ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW II'i EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE UIRE A SITE P N. DATE: � O - 21'� S SIGNATURE: ��Q � �--� PRINT NAME& TITLE: L/ i S Y1�.L ��U K (�_ Rev. 10/OI/IS ; � . � The Commonweakh ofMassachusetts Department oflndustrialAccidents ' O�ce oflnvestigations ' I Congress Street, Suite I00 Boston, MA 02II4-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses . �i Applicant Information Please Print Le¢iblv I Business/Organization Name: -T-1-e�-ri Co��oq �BR �,R� ►�v2• r.�+vem�e�cC. Address: �-151 �t4�io�,r��✓P_ City/State/Zip:ci.��ru�a.l-6,, m .p a� Phone#: So£s - �'ik-'7 ScSZ� Are you an employer?Check the appropriate box: Business Type(required): 1.� I am a employer with�employees (full and/ 5. ❑Retail or part-time).' 6. ❑RestaurantBaz/Eating Establishment __ . _ _ — � 2. I am a sole proprietor or partnership and have no - -` 7. ❑ Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We ue a corporation and its officers have exercised 9. ❑Entertainment their right of exemp6on per c. I 52, §1(4),and we have 10.�Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organizarion,stafFed by volunteers, 11.� HeaUh Caze with no employees. [No workers' comp. insurance req.] 12.❑ Other 'Any applicazrt thaz checks box#1 must also 5ll out the sectioa below showing their workers'compensation policy informatioa. � ••If the coiporate officecs have exempted themselves,birt the wiporatioa has other employees,a workers'compensation policy is required and such an organi7ztion should check box#I. I,am an e»iployer that is providing workers'compensation insurance for my employees. Below is the polacy information. . Insunance Company Nazne:_� �f�[�}oe.,i,(�rc . Insurer's Address: City/State/Zip: Policy#or Setf-ins. Lic.# O 1 L-1 C)CYi 56 221 b 11 Z-1 Expiration Date: 1 — l ^ 2�� Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration date). Fail�se 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 impnsonment,as welias civ�penaTries in tfie fo�a STQP�VORK IIADEP.an�a�ne 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 ce ,under the pains and penalties ofperjury that the information provided above is true and correct Signature: v �--� Date: \0.-2"l-l� Phone#: SoEs -52�-1- "33�y Offuial 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. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �''.. '`�`QR�� CERTIFICATE OF LIABILITY INSURANCE DAT�O/��JZ(NS VY) 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 CONTR4CT BETWEEN THE ISSUING INSURER(S�, AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holtler is an ADDITIONAL INSURED,the policy�ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions oftha policy,certain policies may require an endorsement. A statement on this certificate tloes not conter rights to the certificate holtler in lieu of such endorsemenqs�. PRODUCER N�EA« Deboreh HathaHay G.H.Dunn Insurance Agency, Inc. vHONe �5pg�3�-g2q2 F^� Spg 372_3243 64 Fairhaven Road �nrc,Ho�:� � PoBox497 nooRess: ��rah�ghdunn.com Mattapoisett,MA 02739 INSURE3i 5 AFFORDING COVERAGE Nacn � uusunersn: MARETAILERS �ppppp INSURED TTeen Corp dba Station Aoz Comrenience Paresh Patel INSURER 8: 457 Station A�e South Yarmouth,MA 026f4 INSURER C: INSVRER D: W SURER E: INSURER F: �' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: �, iHS IS TO CERTIFV TIi4T 7FE PqJCIES OF INSURANCE L1SiED BELOVY H4VE BEEN ISSI�D TO hf INSURED W1fv�D ABOVE FOR 71-E POLICY PEPoOD , INDICAiED. NDTWI71iSTAf�DING ANY REQUF3EMENr, iERM OFt COPDI71qV OF ANY CONR2ACT OR OhfR DOCUN�M Wlhi RESPECT TO WHCH iHS . CER7IFICAiE MAY BE ISSUED OR MAY PER7AIN, hf INSUiANCE AFFOROED BY hE POLIGES DESCPoBED.FEREIN IS SUBJECT 70 ALL 7HE IERMS, EXCLUSIONS AI�D COPDIilOrS OF SUCH POLICIES.LIMI75 SFIOWN M4Y H4VE BEEN REDUCED BY PAID CLAIMS. ' LNTR T�'PEOFINSURMlCE U� POLICVNUMBER MIDDfYVFYV MM%DD/YEVVY LIMITS . COMMFRCIALGEI�RALLIP.814TY EACHOCCLRRFNGE $ DNv1AGE TO RpJ�� CLAIMSMADE �OCGUR PREMISES Eao rence $ bEDE%P(Myoneperson) g PER�I�WL dADV I�JJJRV $ GENL AGGREGATE LIMT APPLIES PER: GENFRAL AGGREGATE $ POLICV � �T � LOC PROOUGTS�GOt.�/OPAGG S OThER. g AUTOMOBILELIRBILITY COMBINm51NGLELIMR $ a r rR AM'AUTO BO�ILV IWIRV(�r Person) 8 ' PLL OWNm SGHEDULED AUI'OS AUTOS BODILV INHRV(Fpr accbent) S � HREDAUf0.S ��'�� PROPERTY DPMAGE AUr05 Peraccben $ $ ' UMBRELLALIqB p�CUR EACHOCIX.RRBJGE $ � EXCESSLIAB CLNMSM<DE AGGREGATE $ DED REfENfION$ $ A WORKERSCOMPENSATION O'IQOOOSO�Yl'IE'I'I4 O�(O�/ZO�S 01/01/2016 P� �TH" ANO EMPLOYERS'LIPBILITY Y�N r STATIfrE ER ANV PROPRIEfORiPARMEWE%ECUiNE EL.E4CHAGCIDEM 8 SOO,OOO � OFFICERIMEMBEREXCLUOE09 N� NIA (Mantlatoryln NH� E1.DISEASE-FA EMPLOVEE $ �� If yes,tlesttibe untler DESCRIPTION OF OPERATIONS bebw E.L.qSEASE-POLIGV LIMIT $ �� DESCRIGTION OF OPERATION51 LOCATION51 VEHICLES (ACORD 101,MtlXlonal Remarks Schetlule,may be attac�otl If more speee Is requi�etl) CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULDANY OF THE A60VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUIHORIZED REPRESENTATVE//��ry�r� . �� O 7958-2074 ACORD CORPORATION. All rights reserved. ACORD 2b (2014/01) The ACORD name and loeo are regisMred marks o}ACORD