HomeMy WebLinkAboutApplication and WC ;. � .:. ;SS�t��TQ�...F�Fs
`' �* � TOWN OF YARMOUTH BOARD OF HEALTH � - ;
� � � � APPLICATION FOR LICENSE/PERMIT-201 � ,� �- � �' �
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�'°°' * Please complete form and attach all necessar�y pcumen s e e ber �
' Failure to do so will result in the re�uzri o�yau�a���ir�a.tio.�p cket�� �� � .��-
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ESTABLISHMENT NAME:5'/7 � - _ TAX ID:
LOCATION ADDRESS: 5 /1') , lv� O Z6�3 TEL.#: 7&- 7.S-S� 2
MAILING ADDRESS: 60 2-
E-MAIL ADDRESS: �'c�, rr�czrra rr�� �` a m4-r��.
OWNER NAME: j trs�v h Irt a�3�-
CORPORATION NAME (IF APPLICABLE): �a�.pll�az.�.�,e���_. 2 h c.
MANAGER'S NAME: �osE h Y►tiw-�r,�a TEL.#: 7� s'-�S�az
MAILING ADDRESS: Pa a�C 4�&�1 U�• � , � 8���
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.
— — -- --------___ 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. G�1 i2�'S�/'r?� �dc R�� 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
__ _ __ 1. �h2,r�s�i�r��4 � 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
ass 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. c�,.r s �-,1�►�. �.,6u�,c,� 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 I
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. 3 2. ��v C�'� �-�yle� :
3. PI��►-•D n—k �1�...►�� 4. -��r�,� �� �-vr�A-_
RESTAURANT SEATING: TOTAL#
_---- -----9��'�££�3��£�l>IL�'__ __ __— --_
--- -- __--- __ .-- -
LOUGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
[NN $55 CAMP $55 SWIMMING POOL$110ea.
_LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 ��.�j CONTINENTAL $35 p NON-PROFIT $30
_>100 SEATS $200 �COMMON VIC. $60 ��/C� =WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LIC�NSE 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 _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ �,g S•O� '
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** :
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ADMINISTRATION ` ` a �
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 f
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE '
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR '
i
�
CERT. OF INSURANCE ATTACHED ?� f
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 �
�
�
i
MOTELS AND OTHER LODGING ESTABLISHMENTS �
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 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 k
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 area until the pool has been ,
inspected and opened. !
I
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count j
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 �i
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be �
obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, i�
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 Board of Health.
OUTDOOR COOKING:
Outdoor cooking,preparation,or display of any food product by a retail or food service esta.blishment 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, 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 REQ IRE A SITE PLAN.
DATE:��/� SIGNATURE:
PRINT NAME&TITLE: i4-��°�/�sG'� n-
Rev. 10/O1/15
� � . �'
� The Commonwealth ofMassachusetts
f , Department of Industrial Accidents
i � Office of Investigations
' 1 Congress Street, Suite I00
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: S�s�a/6G� �1��-r�h�� �'nC Of3�_������� �'
Address: �1� m�h� S f.
City/State/Zip: (,(,,_(,��',�ay,�� /�- G 2��3 Phone#: �'7�-3�5�-.�5� �-
Are you an employer? Check the appropriate boz: Business Type(required):
1.� I am a employer with employees(full and/ 5. ❑ Retail
or part-time).* 6. �Restaurant1Bar/Eating Esta.blishment '
- — --
2. I am a sole proprietor or partners ip an ave no -- -'
7. ❑ 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]* 11.0 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 is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
Ci /State/Zi :
tY P
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
- - �ine up�o�1,506.�an�r one=year impns`onment,a§we1T as�pena�Ifies in�tie�orin o a �ORI�t3RB�R and a�irie
of up to $250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,u r the padns an penaltie f perjury that the information provided above is true and correct.
Si ature: Date: �� /3 lS
Phone#:
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. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
.
� `/ , � DATE(NM/DOIYYYY)
� ,4co�ro CERTIFICATE OF LIABILITY INSURANCE
11/16/15
THS CERTIFICATE IS ISSUED AS A MATTER OF II�ORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER THIS
� CERIIFICATE DOES NOT AFFIRMAIIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLJqES
� BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITU7E A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTFIORIZED
REPRESENTA7IVE OR PRODUCER,AND THE CERTIFlCATE HOLDER.
� IMPORTANT: If the certificate holder is an ADD1710NAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions ofthe policy,certain policies may require an endorsement. A statement on this certificate dces not confer ri�ts�the
; certificate holder in lieu of such endorsemen
� PROd10ER CONTACT
j NAhE: BY'1dA �181II
� Choice Insurance Agency, Inc. PHONE , g00 649-4853 �N : (9�a) 345-1007
376 Su�aer Street e.Ma�
Fitchburg, MA 01420 Ao�Ess: choice@choice-insurance.com
INSURE S AFFORDING COVERAGE NAIC#
in�suR�a:Scottsdale Insurance Co an
INSURED INSURER B:
Sandbar Holdings LLC iNsuR�c:
dba Cape Cod Family Resort ��RERD:
512 Main Street, Rt 28 �NSURERE:
West Yarmouth, MA 02673 INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LJSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMm ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHiCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TFE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLJCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
� INSR AODL SUBR POLICY EFF POLICY E7�
LTR TYPEOFINSURANCE POIJCYNUAiBER M/DDN MNID�VYYYY LIMTS
A �"�^���uTM CP51898314 s/2a/�5 3/24/16 �,cHoccuw�Nce s 1 000 000
X COMMERCIALGEf�R4LLIABILITY DAMASETORENTED $ rjO OOO
CLAIMSauIADE �OCCUR MED Dff�(Arry one persan) $ S OOO
' PERSONAL&ADV INJURY $ 1 OOO OOO
GENERAL AGGREGATE $ 2 OOO OOO
GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-ODMP/OPAGG $ 1 OOO OOO
POLICY PRa LOC $
AUTOMOBILELU161LRY COWSIN�D�SMGLELIMIT $ �
ANYAUTO BODILY INJURY(Per person) $
ALLOWPED SCHEDULED BODILYINJURY(Peraccident) $
AUTOS AUTOS
NON-OWNED PROPERfY DAMAGE $
HIREDAUTOS _AUTOS eraccident
$
UNBRELLALIAB OOCUR EACHOCCURRENCE $
IXCESSLIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$
YNDRKERS COMPEN5ATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N
ANYPROPRIETORIPARTNERIEXECUTNE � E.L.EACHACqOEM
�FICERIMEMBER DCCLIAED? N�A
(Mandabry in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPER4TIONS below E.L.DISEASE-POLICY LIMIT
A Liquor Liability CPS1898314 3/2a/is 3/24/i6 1,000,000 2,000,000
DESCRIPTION OF OPERATIONS/LOG4TIONS/VFJiICLE3 (Atlach ACORD 101,Addifional Renerks Schedule,if more apace is requ red)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TI� EXPIRATION DAlE THEREOF, NOTICE WILL BE DEIJVERED �I
TOWII of Yarmouth ACCORDANCE WI7H 7HE POLICY PROVISIONS.
Route 28
Yarmouth, MA OZ6G4 AU7HORIZEDREPI�SENTATIVE
Brian Allain
O 1988 2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The/LCORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail: