HomeMy WebLinkAboutApplication and WC� : ���a
TOWN OF YARMOUTH BOARD OF HEALTH
� � � � APPLICATION FOR LICENSE/PE _ , T� � �t� "s t� 2�15
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Please complete form and attach all necessary do ,en - :' eQc' � 201 S.
Failure to do so will result in the return of yc�u,ap 'ea�i'br�`ac H DEPT.
ESTABLISHMENT NAME: w « �., � o s� TAX I •
LOCATION ADDRESS: Q� a�-} Q�(ti �,��� S�-. S. J�..��., �..,� TEL.#: S��--3�-c�-- u y�
MAILING ADDRESS: Q�,o,._ ��,,.r.�S , Cc.c, {��-r.�v �.� t�...�.��� i�„�y►t�a� ��.�L
E-MAIL ADDRESS: (�L,�.�-l�.rnw� v«��.q,:�.es. «�.
OWNER NAME: P,__,��r':�.e•5 -��
CORPORATION NAME(IF APPLICABLE): P�o� G��,a� s �.�.
MANAGER'S NAME: �,�� , �,,,�,�.,,,� TEL.#: �Q'I- �c� -,��
MAILING ADDRES S: P�,-- r.�..,._3 � �c� Q�v�,b�-...� -1�,,.....,. n.�.� �_, ,�•,r� �:z�:�.�.
P CERTIFICATIONS:
The poo s isor must be certified as a Pool Operator,as required by State law. Please li e designated
Pool Operator(s) ttach a copy of the certification to this form. _ =�"
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Pool operators must list a minimum of two employe �e�tly certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one,cer�ifie loyee on premises at all times. Please list the
employees below and attach copies of their cei-�'�ca'tions to this for . he Health Department will not use past
years' records. You must provide n opies and maintain a file at y • lace 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. i
You must provide new copies and maintain a file at your establishment.
1. � � "�o�s� 2. ;
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. .
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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.
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1. �s� �o�...��.:._ 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.
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3. 4.
RESTAURANT SEATING: TOTAL# �i�
_ _ --- _ -- QFFIC.E II:�_.�NI�X---- - -----_ _ _ ---__ _ i
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55 MOTEL $110
_INN $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 CONTINENTAL $35 NON-PROFIT $30
�>100 SEATS $200 �� �COMMON VIC. $60 �(02 —WHOLESALE $80
RETAIL SERVICE:
—RESID.KITCHEN $80
LICENSB REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25
_<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110
NAME CHANGE: $15 AMOUNT DUE _ $ 260•00
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** I
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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 prior to renewal or issuance of your permits. PLEASE CHECK '
APPROPRIATELY IF PAID:
YES ✓ NO
MOTELS AND OTHER LODGING ESTABLISHMENTS k
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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. '
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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 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.
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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 i
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.
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FROZEN DESSERTS: i
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 establishment is prohibited.
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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.
I 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
I TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: . i � '" SIGNATURE: L--� I`.��� .�..
PRINT NAME & TITLE: Lt-�dz�,.. 13,,+1.�.� �6' Q�s�-:�+�-
Rev. ]0101/15
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� The C`o�nmonweatfh o M'assachuseits
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' � Deparfinenf oflndustr:ialAccide�is � � �
{ _ ' X Congress,Sfreef,Suite X00
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; :8osfo�z,MA O�XX4-20X7
•� www mass:gov/dia
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Workers'Compensafion Insarance Affidavi�:General Businesses.
TO B�FILED WITSTS�PERMITT,ING AUTHORITX.
Abblican�Information PIease Prinf Le�iblv
Business/Organization Name: P� ,r,;, �� �, r .
I Address:_ �-� �� ct�i o h1 o�-c O��S�x.} .
CitylState/Zip: � �,,,-- ,�� Phone#• �Fr-3�i�— '���t�
Are you an empIoyer?Check fhe appropriate box: Business Type(required):
; 1.[]V'T am a employer with ���� employees(full and/ 5• ❑Retait
2.[ or part time).* 6. �estanrantBar/Eating Establishment
I am a soIe proprietor or parEnership and have no
� employees working for me in any capacity. 7• ❑Office and/or Sales(incl.real estate,auto,etc) '
[No workers'comp.insurance required] 8• ❑Non-profit
3-❑ We are a corporation and its officers have exercised 9. ❑Entertainment
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their right of exemption per a 152,§1(4),and we have 10.[]Manufacturing
4.❑ no employees.[No workers'comp.insurance requiredJ* 11.[]Health Care
We are a non-profit organization,staffed by voIunteers,
with no employees.(I�To workers'comp.insurance req] 12.[]Other
*Any applicantthat checl�box#1 must also fil[outthesection belotvshowing their�vorkers'compensation policy infbcmation.
'#If the cotpotate officets have exempted themselves,but lhe corpocation has ott�er emptoyees,a tvorkers'compensation poliey is required and suchan '
organizationshould checl:box#1.
I anrau efnployer tliat isproviding�vorkers'co�rrpeusafiorz iusuraucefor t�iy ettrptoyees. Belo�v is fkepolicy irrfortnalio�a
Insurance CompanyName• Unifed States Fire Insurance Company(Crum and Forsfer) '
Insurer's Address: 305 Madison Ave,PO Box 9960
City"/StatelZip: Motristown�NJ 07962 •
PoIicy#or SeIf-ins.Lic.# 5439959829 Expiration Date: 6/30/204 6
Attach a copy of fhe�vorkers'compensation policy declara�iott page(sho�ving the policy number and expirafion date).
i
i Failure to secure coverage as required under Secfion 25A of MGL c.I52 can Iead to the imposition of criminal pena(ties of a
fine up to$I,500.00 and/or one-year imprisonment,as well as civcl penalties in the form o£a STOP WORK ORDERand a fine
of up to$250.00 a day agaictsE the violator. Be advised that a copy ofthis statement may be forwarded to fhe Office of
Investigations of the DIA for insurance coverage verification. �
X do Itereby cerfi nder fliepains a�tdpetzatties ofperjrcry fliaf tlte infortt:aiionprovided above is true and correM
Si nature• � Date• fr �
Phone#: �-Srl— �-E�.t— \��
Official use ortty. Do not�vrite in fkis area,to be complefed by city or fofvn official.
i City or To�vn: Permit/License#
Issuing Authority(circle one):
I.Soard of$eaIth 2.Suitding DeparEment 3.Cify/To�vn Cierk 4.Licensing Board 5.SeIectmen's Office
6.OEher '
ContacE Persom Phone#:
�nvw mass.gov/dia
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ACO�" SPECBRA 01 EBORTNIKER
�� CERTlFICATE O� LtAB[LITY tNSURAt1[CE " �a�cMMron^�rn
THIS CERTlFICATE !S ISSUED AS A MATCER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CER7'IFICATE HOLDE2R.THIS
CERTIFICATE DOES NUT AFFIRMATIVELY OR NIEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES
BELOW. THIS CERTIFICATE OF lNSURANCE DOES NOT CONSTITU'fE A CONTRACT BETWEEN THE tSSU1NG INSURER(S),AUTE(ORIZED
REPRESENTATiVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTART: tf the cerfificate hotder is an ADDITtONAL INSURED,the poticy(ies)must be endorsed. If SUBROGAT[ON IS WAIVED,suBjectto
the ferms and condiftons of the policy,cettatn policies may require an e�dorsemenf. A sfafemenE on this cetEifcafe does notconfer righfs Eo the
cerfificafe hoider jn Iteu of such endorsement(s).
PRoouc� ��.A�
KrauEer&Com any NaM�
1350 Avenue o�t6e Amertcas p�NNo�,n:'1(2T2)596-3400 F"X 4(272)596-3460
48f[�Ftoor E,h��� A!C No t
New York,NY 40049 aonsess•
� INSURER(S)AFFORDIH�C�VERAGE NAIC#
j INSURED INSURERA:Unifed Sfates Fire Insurance Company 24'I93
' wsus�s:Charter Oak Fire Insurance Company 2S64S
i Specialfy Brands Hoidings,LLC iNsue�c:Nafional Union Fire Ins.Co.of Pitfsburgh PA 19445
i 260 Ftantdin St
� SuiEe 1860 , �nisus�n:Crum&Fors�Eer indemnity Company 34548
Boston,MA 02740 INSURERE:
INSURER F•
COVERAGES CERTIFICATE NUMBER: . REV(SIO[�NUMBER:
'f'HlS IS TO CERTII-Y THAT THE POlIC1ES OF INSURANCE LIS7ED BELOW HAVE BEEN(SSUED TO'fHE INSURED MAMED ABOVE FOR'FHE POLtCY PERIOD
INOtCATEO. NO'fWll'HSTANDtNG ANY REQUIREMENT.TERM OR CONDITION OF AMf CONTRACT OR OTHER DOCUMEM'W17fi RESPECTTO WH(CH i'NI5
� CERTIFICATE NWY BE ISSUED OR MAY PERTAIN, THE (NSURANCE AFFORDED BY THE POUCIES DESCRtBED HEREIN ISSUBJECTTOALLTHETERMS,
� IXCLUSIONS AND CONDITlONS OF SUCH POLICIES.LIMITS SHOWN MqY HpVE gEEN REDUCED BY PAID CLAIMS.
�I.IR 'iYPEOFINSURANCE A�0 5 BR POUCYEFF POUCYEXP
INSO WVD POLlCYNUMBER MMID� M611DD1YYYY Ufd1iS
A X COMMERCIALGENERqLUABIUTY
EACHOCCURRENCE S 4�OOU�000
' CWMS•MqoE �oCCUR 5439959629 06130/204b 06/30/2016 p��sEs oxumence 5 4,000,000
MEDEXP(Myonepe�son) 5
PERSONAL&ADVIMJURY S 'I�000�000
GEN'LAGGREGA'fELIMITAPPUESPER: GENERALpGGREGATE S 'IO�OOU�000
x POUCY❑JEC ❑LOC
PRODUCiS-COh(plOPAGG S 2�000�000
OTHF�i; S
AUTOMOBfLE UpBILCIY COMBINED SINGLE LIMIT
g Eaaeudert S 4�000�000
ANYAItTo BA3D54518975AUF 06/30f2015 06/30I2016 BOOiLYINJURY(Perpersoo) S
��eo X a�u�H-osu�o
# X HIREDAVTOS X NaN�OWNED � BODILYINJURY(Peracddeng S 4,000�000
AtJf05 Pe�PardenOAMAGE 5
S
X UMBRELLAlIAB X p�CUR EACHOCCURRENCE S 25�000�000
C IXCESSUA6 CtAtMS.MADE BE035825562 O6130/2095 0613�I2046 p��GATE 5
DEO X REIENf(ONS �0�00� Aggregate S 25�000�000
WORKERS COMPENSA710N PER O7H-
ANDEh1PLOYERS'LIABIUSY STATUiE ER
� d ANYpROPRIETOR1PpRTNER/F�(ECUINE Y�N OB7267263 06f30/2095 O6I30/2016
' OFEICEH/ME(dBEREXCLUDEO? �N!A E.LEACHACqQENT S 9�QOO�OOO
� (MandatorylnNH)
!fyes.desenyeunde� ELOISEASE-EAEMPLOY S 1,000�000 '
� OESCRIPTtONOFOPERATiONSbefow EI.DiSEASE-POLICYUMIT 5 4,000,000 '
OESCRIP'iiONOFOP6RA'iIONSlLpCATlONS/VEti1CLES(ACORD101.Addfllona(Rem�ritsSehedute.may6eaNaehedlfmo�espaceistequfredJ
PeoptesBank is named as additional insured with respecE to the operafions oF the named insured and as required by wriEten confract
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j CERTtPlCATE HULDER CANCELlATION
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j SIiOULD ANY OF THE ABOVE DESCRIBED POLlC1E5 BE CpNCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOttCE WIlL BE DELIVERED !N
� Evidence pCCORDANCE WtTH THE POLiCY PROVlSfONS.
AUTHORIZED REPRESENTA'fiVE
`,��,:�,�-
01986 2014 ACORD CORPORATION. AII righfs reserved.
� ACORD 25(2074/01) 1'he ACORD name and fono are reaistered mark��f ncnRn
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j AG�NCY CUSTOMER(D:SP�CBRA 04 ASMITH
I. ��� � LOC#; 2
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� �...� ADD[T[�C�[�►t,.. REI1f[AR[�S SGH�QU[..� � Page � of �
AGEFICY NRMEO(kSURED
KraRfer&Cotttpatly,LRC Specialty Brands Holdings,LLG
600 Providence Highway
poucYHunseeR • Dedham,MA 02026
S��pAGE q
CARRIEEt }2p(CCO�E
SEE PAGE�i SEE P 4 EPEEC'iNEpASE:S��PAGE'I
ADplT[ONAL.REMARKS
THlS ADDlTtONAL REMARKS FORM 1S A SCHEDULE TO ACORD FORM,
;EORM NUMBER: ACORD 25 �ORM T1T[.E:GedlFicaEe oFLTabliiEt►insuranoe
I Remarks:
I Additionai I�Iamed trtsureds:
i
1 Papa Gino's,(nc,
� Papa Gino's Hoidings,Gorp.
papa Gino's�ranchising corporafion
Pa�a Gino's�D`AngeIo Card Services,Inc.
D'Angel�Franchising Corp.
D'Angeio's Sandwich Shops,[nc.
'�he Smith&WoI[ens[cy Resfauran�Group,Inc. �
S&W of Miame,L.L..C.(L7E)
S&W�.C.,L.L.C.(DE)
Smifh&Wo![ensKjr of Bos�on LLC(DE}
5mith&IlitoIlenstcy of Housfon L.LC(DE}
1lVoi[ensky Beverage,lnc.
Hous�on S&W,L.P.
S&itif of E.as Vegass C..L.C.(DE) .
S&1!V of Phitadet(�hia,LLC(pE)
Smitt�&Itilol[ensky of Ohio LL.0(DE)
� Smeth&{titoltensky of America LLC
� �t Washing�on Avenue Gorp.
Projec�Gri[[i
PGHC Hotdings,inc. • • '
Defops,tnc. .
SouEh Poinfe Hos�ifality,inc.
Projec�Gritl 1[
progressive Eood,Inc.
Smith&Wol[ensky Afiantic WharE[.L.0 �
s&Uft chicago,l,L.c.
ACORQ 40'[(2008/841 �200B AC�Rh CORPORATION_ Ait dnhfc resetved.