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Home My WebLink AboutApplication and WC�� .� , � � TOWN OF YARMOUTH BOARD F HEALTH � �L OMCD '" � � APPLICATION FOR LICENSE/PE � 3° '� s ��+ 2 2�� `�' �� x � 2 * Please complete form and attach all necessary c ` �' � e ` r 15 20T2. Failure to do so will result in the return of your application ac H DEPT. ..�.. ESTABLISHMENT NAME: ' X ID: LOCATION ADDRESS: �! W + � TEL.#: b�8 '7 O•1� MAILING ADDRESS: � � � OWNER NAME: o +�� CORPORATION NAME ( APPL CABLE): 1VTANAGER'S NAME: i TEL.#: MAILING ADDRESS: ��Y�1 POOL CERTIFICATIONS: The pool supervisor must be certifed as a Pool Operator,as required by State law. Plea�e list the ciesignated Pool Operator(s) a.�cl attac�a c��y of tlae certificax�on�io this��1. l. 2• Pool operators 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 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'reeords, You must provide new copies and mai tain a file at your establishment. `- , 1. �� Y\ � 2• - _ i�R�iC�P..�r"�e$�.�:-U�: __ _ _ --— _ -- _ Each food establishment must have at least one Person In Charge(PIC) on site during hours of opera.tion. 1.��25 I � 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the �3Pimlich 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're�cords. �ou must provide new copies and maintain a file at your place of business. 1. �� I� 2. 3. 4• RESTAURANT SEATING: TOTAL# �Z-� - I OFFICE USE ONLY I LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �i B&B $55 _CABIN $55 _MOTEL $55 � ---INN $55 _CAMP $55 _SWIIv11VI1NG POOL $80ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $160 �t3'�S� �COMMON VIC. $60 �r3-�y� _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQiJIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 <25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95 _ NaME c�►NCE: $i s AMOUNT DUE _ $ 2 2.0.o o _ *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �1 R!.*A^'111 F im �� . c 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 p ' r to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MO`�`�;S AND'O'T"HER I:�HGIl`�G E�Tz��S��M�l1��'� , 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 sha11 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 OPEIVING:All swimming,wading and whirlpools which have been closed for the season must be inspected ' b the Health De artment rior to opening. Contact the Health De arhnent to schedule the inspection three(3)days Y p p . � . . prior to opening.PLEASE NOTE:People are NOT allowed to sit m the pool area until the pool has been mspected 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 thereafter. - _ _ -;_.t.__ _ -� .___ 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.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 servic�l,must have�riox_a��rov.�l fre�*h��r�ttl#�— OUTDOOR COOKING: 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 E BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS A PLAN DATE: 4 C ` �Z� i Z� SIGNATU . PRINT NAME& � / �Q,E J� Rev. 10/09/12 : ; r r � The Commonwealth of Massachusetts � 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 Apulicant Information Please Print Legibly f Business/Organization Name: c�o Vy-�S I��CSL�.(,_�k�'P/1/Yl L-L.� _ � i Address: v (� �� ' City/State/Zip: �� v ��C(, Phone#: ��g - �!��'l��v I Are yo n employer?G�i�ck tb�ap�og�iate�:�-, -::;.-- _ -B�rsiness'F�pae(requireid�: _ _ 1. I am a employer with�employees(full and/ 5. ❑ Retail j or part-time).* 6. taurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �. �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 are 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 are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an � organization should check box#1. I am an employer that ds providing workers'cOmpensation insuraCn_c�e for my employees. Below is the policy information. Insurance Company Name: L.t�QU� i:'��%�"u�s� �S � j Insurer's Address: i'%S I�ERK��.C'/ ST7��C� i i City/State/Zip: C30S`T�N . �� 2./l`7 � _$ • • -�..� �,,-��-5°�-��d��-- ' --� �� -- - £xp�atian�e:-- c�` `� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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-year 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 forwarded to the Office of ; Investigations of the DIA for insurance covera � cation. I do her y cerii the ' s a pena ' that the information provided above ds true and correc& Si a e: Date: �! ` �� Phone#: ! Official use only. Do not write in thds area,to be completed by city or town official ��, City or Town: ��CL"(�'}' Permit/License# �"` ��,��'�" Is t ' cle one): Board of Healtt . uilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6. Contact Person: Phone#: �,'g—�Q�Q--�� X/�-`r/ , ,_ � ,. _ �. _.:___ , ,_ www�:�ass:gova�ia , r i""'1 ARDEO-1 OP ID:PB `��-R�''� CERTIFICATE OF LIABILITY INSURANCE °A'�,M�°°"'"""' 11/16/12 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 AITER 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subJect to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s. PRODUCER Phone:508-528-3310 �ryNjE CT ' Keefe Insurance Agcy.inc i 51 West Central Street Fax:508-528-3887 ac°NN e:�: ac No: P.O.Box K E-MAIL I Franklin,MA OYOSH ADDRESS: Peter L.Brunelli INSURER(S)AFFORDING COVERAGE NAIC# iNsuReRa:Liberly Mutual Ins.Co. INSURED South Side Tavern LLC dba INSURER B: Ardeo and Ardeo at Kings Way 23V Whites Path INSURER C: South Yarmouth�MA OZBC� INSURERD: - INSURER E: '� INSURER F• COVERAGES CERTIFICATE NUMBER: 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. NOTWITHSTANDING ANYREQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 4VHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE IMSURANCE 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. ��7� TYPE OF IN5URANCE pOLICY NUMBER M��Y EFF MM/DD� LIMITS GENERAL LIABILITY � EACH OCCURRENCE 5 ' COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrer�ce S i CLAIMS-MADE �OCCUR MED EXP(Any one person) 3 �� PERSONAL 8 ADV INJURY 3 � � GENERALAGGREGATE b i GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 5 POUCY PRO- L� a AUTOMOBILE LIABIIJTY COMBINED SINGIE LIMIT Ea accideM $ � ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS � NON-0WNED PROPERTY DAMAGE � HIRED AUTOS AUTOS Per accideM $ g i UMBRELLA LIAB OCCUR EACH OCCURRENCE 3 � EXCESS LIAB CLAIMS-MADE AGGREGATE $ � DED RETENT�ON$ y ' WORKERS COMPENSATION X WC STATU- TH- ; AND EMPLOYERS'LIABILITY T Y Ih TS ER � A ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N C531S384O40022 05/OHM2 O5/OH/13 E.L.EACH ACCIDENT y 'I OO,�� OFFICER/MEMBER EXCLUOED9 � N�A M (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ ��,�0 If yes,describe under � DESCRIPTION OF OPER,4TIONS below E.l.OISEASE-POLICY LIMIT a 500,00 � DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additlonal Remarks Schedule,if more space ia requlred) Restaurants at 23V Whites Path South Yarmouth and 81 Rings Circuit � Yarmouthport, MA CERTIFICATE HOLDER CANCELLATION YARMO-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth rHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Main Street Yarmouth�MA OLGG4 AUTHORIZED REPRESENTATNE � Peter L.Brunelli �,��,� �� *�� "�� `vtii�"�� I OO 1988-2010 ACORD CORPARATI�N_ AI�,ri8htc_rpcarvpd, ' ACORD 25(2010/05) The ACORD name and Jogo are registered marks of ACORD ' _ �