The URL can be used to link to this page

Home My WebLink AboutApplication and WC r 'i � � TOWN OF YARMOUTH BOARD,O��IEA�,TI3 : G3C(;LSp�JC�sp � � APPLICATION FOR LICENSE/P�1�MI'�� 1� � � �, � �� "'°°� * Please complete form and attach all necessary docu� s� - � E�e ber�� 15� ' Failure to do so will result in the return of your application p cket',;,r��.�.H DEPT. ESTABLISHMENT NAME:��` �' i-�-C L.�'l�-�1 L.��-,G TAX ID: -- LOCATION ADDRESS: �q � M A�� `� �� mA �7� TEL.#: $��1��(�q� MAILING ADDRESS: �''A-�►� E-MAIL ADDRESS: �� t�� ' `''��-+ i . �t'►�l OWNER NAME: '��F�1C.-� '� � -t-- CORPORATION NAME (IF APPLICABLE): �i�"f� 1-L-C- MANAGER'S NAME: �L.��k� �� TEL.#: �"t?��- 71 1��(n�i�i MAILING ADDRESS: �A�'� 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. i.�A°c�1r��cK�i t�v"kz. t�.: �#�'�l'c.1��:�r'�.fk- _ -=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. T L�SH ��C��-� 2. Sf��-,t'�(Z '�'�l��F1'I- 3. �P��h� �C�i-i C� 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. 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 form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL # _ - - __ _ _----- 0��'�`E��' - - - LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNJ IT# B&B $55 CABIN $55 MOTEL $110 l�o��3 _INN $55 CAMP $55 �SWIMMING POOL$il0ea�� _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $I l0ea. (o^ FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# L CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 �CONTINENTAL $35 �/1�3 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 VENDMG-FOOD $25 =<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ 365-00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** r � 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 ATTACH�,D STATE VVORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF 1NSURANCE 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 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. 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. 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 obtamed at the Health Department,or from the Town's website at www.varmouth.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 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. 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, 201 S. 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 REQUIRE A SITE PLAN. �DATE: �l_ �_ ,��I`� .� SIGNATURE: '� �PRINT NAME & TITLE: �C.s-Sk} \��.,A=-► C--�►'►� Rev. ]0/O1/IS Client#: 19255 2ECONOLODGE DATE(MM/�D/YYYY) ACORDrM CERTIFICATE OF LIABILITY INSURANCE 11J23/2015 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 CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE 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 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). CONTACT PRODUCER NAME: Dowling&O'Neil Insurance Ag PHONE 508 775-1620 aC No; 5087781218 A/C No Ext: 973 lyannough Rd, PO Box 1990 E-MAIL ADDRESS: Hyannis, MA 02601 INSURER(S)AFFORDING COVERAGE NAIC# 508 775-7620 iNsuRERA:Guard Insurance Group INSURED INSURER B: Di pti LLC INSURER C: _ c/o David Patel; 59 Route 28 INSURER D: _—._—___. West Yarmouth, MA 02673 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: REVI510N 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 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. INSR TypEOFINSURANCE ADDLSUBR pOUCYNUMBER MM/DDY/YYYY MMlDDYEXP UMITS LTR INSR WVD GENERAL LIABILITY EACH OCCURRENCE $ _ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE �OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER: PROOUCTS-COMP/OPAGG $ POLICY PRo- LOC $ AUTOMOBILE LIABILITY Ea aBc tleDiSINGLE LIMIT $ 80DILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accideni $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ --- A WORKERSCOMPENSATION BINDER404182 11/24/2015 11t24/201 X W�STA�U-S ORH- � AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVEY�N E.L.EACHACCIDENT $rJOO�OOO ____ OFFICER/MEMBER EXCLUDED? � N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $rJ�O 0{)� If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $S � DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived, or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRI6ED POLICIES BE CANCELLED BEF�RE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOl10E WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE .�,�,�. �t',.�`� OO 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S161396/M161395 NS2