HomeMy WebLinkAboutApplication and WC 4�;�"�k�i t�,�r RESo2T
' � TOWN OF YARMOUTH BOARD OF HEAL�'� ''.: ;±< - �
� � APPLICATION FOR LICENSE/�ERMYT-2016 ' �€� ;�� f�;���
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* Please complete form and attach all necess�..docu��e t�y�ec' er S �, j�,�
Failure to do so will result in the return of yca�r�application p� et. ��',��'r �
ESTABLISHMENT NAME: G�P� �d� Ff1P'1'1 i L R�sol� TAX ID:
LOCATION ADDRESS: 5(Z IYJA�i IV 5T IRl�'ST y�21'Y►t�u� t�i�bz67�TEL.#: 5'p�'- 7°7/-o!a�
MAILING ADDRESS: Pc� FJ' 01C � �I w. �l�}�2rnt�t�#� . l�1�. azb�73
E-MAIL ADDRESS: "a s�ct,; ,
OWNER NAME: J s��h mr4�Q�n-ta
CORPORATION NAME (IF APPLICABLE): ,��lNDSAi2 rhi4rV�4�e n�Ervi� I'�Yc .
MANAGER'S NAME: �./o s�Ph yYl�►p.��rv� TEL.#: 9 7 Sr-3?S- 5��
MAILING ADDRESS: P e �3a���� 1�t�,'V�e��c,� V{N4 a�673
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.
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Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardio ulmon Resuscitation CPR havin one certified em lo ee on remises at all times. Please list the
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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.
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3. i�b-S%1,�,� P.�s��.w 4. Jm c Foi, Yhr��o a��
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.
l. 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 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. 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 fortn. 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#
---_ __-- -- ---- �FF�CF}_u�_F a�t��-----_ _
____
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT#
B&B $55 CABIN $55 MOTEL $110 �I��OI°J
_INN $55 CAMP $55 �SWIMMING POOL$I l0ea. �b-6 l Q3`�
_LODGE $55 TRAILER PARK $105 �WHIRLPOOL $110ea.��c,
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $125 J CONTINENTAL $35 L(e—U �I NON-PROFIT $30
_>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSfi 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 $I 10
NAME CHANGE: $15 AMOUNT DUE _ $ �-75 .OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION � ' � 4 "
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 X� �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �i
�
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 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
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. j
I
POOLS I
r
POOL OPENING:All swimming,wading and whirlpools which ha�e 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. :
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. -
POOL CLOSING: Eve outdoor in round swimmin ool must be drained or covered within seven(7)days of �
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closing. j
___ _ __ _ . _ , _ _ _ , C
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 Deparhnent,
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 COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
. ___ _ . _
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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. ;
;
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 REQUT A SITE PLAN.
DATE: ���/3//S SIGNATURE:
PRINT NAME& TITLE:
Rev. ]0/O1/IS
1
1' ' ��1 � �
The Commonwealth ofMassachusetts
j -. Department of Industrial Accidents
� • y Office of Investigations
�
' I Congress Street, Suite 100
_ Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/Organization Name: ��n ol h�, /�1�.h, ���n� S�c- ��3�C���n
��-„1;Ly �.�or-j—
Address: �/Z lj'l�-�ic.. �•
City/State/Zip: 7,t,_ �/�i-�2wt.dc�'L� ; � oz6�3 Phone#: �I 7�' '3�--�Yo 2--
-�•-�
Are you an employer? Check the appropriate boz: Business Type(required):
1.(� I am a employer with �O employees (full and/ 5. ❑Retail
or part-time).* 6. ❑ RestaurantBar/Eating Establishment
2. I am a sole proprietor or par[ners�iip and have no �, Q Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacrty. '
[No workers' comp.insurance required] g• ❑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 secfion below showing their workers'compensation policy information. '
**If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#L
I am an employer that is providing workers'compensation insurance for my employees Below is the policy informatdon.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
— ---fm��p-ta-� , . - 'r�p:issn�rie��,-as-vv����s-sivi��s-�����e����'O��O�K O�tD�R-��fi�-- - ',�
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,under the pains and enalties ofperjury that the information provided above is true and correct.
//
Si ature: Date: ���/�
Phone#: 9 75' 2
Official use only. Do not write in this area,to be completed by city or town official ',
City or Town: PermitJLicense#
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
� "
',d►co� CERTIFICATE OF LIABILITY INSURANCE °�'�`�"'°°"""",
11/16/15
THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER THIS
CERTiFICATE DOES NOT AFFIRMA7IVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLJqES
BELOW. TFdS CERTIFICATE OF INSURANCE DOES NOT CONSTITU7E A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERrIFlCATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL 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 statemertt on this certifipte dces not confer rights to the
certificate holder in lieu of such endorsemen s.
�aowcaa NA�: T Brian Allain
Choice Insurance Agency, Inc. PHONE . g00 649-4853 �N : (9�8) 345-1007
376 Summer Street AooaaEss: choice@choice-insurance.com
Fitchburg� MA O14ZO INSURE S AFFORDINGCOVERAGE NAIC#
iwsuR�a:Scottsdale Insurance Co an
3 irrsut� �
� Sandbar Holdinqs LLC i�R��.
i dba Cape Cod Family Resort i�R�xo:
j 512 Main Street, Rt 28 INSURER E:
West Yarmouth, MA 02673 INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSl�2ED NAMm ABOVE FOR THE POLICY PERIOD
INDICATm. NOTWITHSTANDWG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
i INSR AODL SUBR pOIJCY NUMBER PM�/YEFF ��D/Y�Y LIMTS
LTR TYPE OF INSURANCE
A �N�A���B�� CPS1898314 s/2a/is 3/24/16 EpCHOCCURRENCE $ 1 ��� QQQ
X COMMERCIALGENERALLIABILITY P�GETORENTED $ SO OOO
CLAIMSaNADE �OOCUR MED DQ'(Arry one persm) $ 5 OOO
�Rsor�aL&,aoVlruURY $ 1 OOO OOO
; GENERAL AGGREGATE $ 2 OOO OOO
GEN'LAGGREGATELIMITAPPLIESPER PRODUCTS-OOMP/OPAGG $ 1 OOO OOO
POLICY PRO- LOC $
� /WTOMOBILELIABIUTY COA�SINEDSINGLELIMR
i aaccider� $
� ANYAUTO BODILY INJURY(Per person) $
ALLOWhED SCHEDULED BODILYINJURY(Peraccident $
AUTOS AUTOS �
�� HIRED AUTOS NON-OWNED PROPERfY DAMAGE $
_AUTOS eraccident
$
UNBF�LLALIAB OCCUR EACHOCCURRENCE $
�. IXCESS LIAB CLAIMS-MADE I AGGREGATE $
� DED RETENTION$ $
VNDRKFRS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY y�N
ANY PROPRIETORIPARTNER/EXEIXITNE
OFFICEWMEMBER IXCLIAED? � N�A E.L.EACH ACp�EM' $
p�Aandabry in NH) i E.L.DIS EASE-EA Bu1PLOYEE $
If yes,describe under �
DESCRIPTIO N OF OPE RATIONS below E.L.DIS EASE-POLICY L IM IT
A Liquor Li3b].lity CPS1898314 3/24/15 3/24/16 1,000,000 2,000,000
(
OESCRIPTION OF OPERATIONS/LOG4TIONS/VEHICLES (Atfach ACORD 107,Additional Rerterks Schedule,if more spece is requred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLIC�S BE CANCELLED BEFORE
THE EXPIRATION DAlE THEREOF, NOTICE WILL BE DELJVERED IN
TO�PIl of Yarmouth ACCORDANCE WI7H 7HE POLICY PROVISIONS.
Route 28
Yarmouth, MA 02664 AUh10RIZED REPRESENTATIVE
Brian Allain
O 1988�010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The I4CORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail: