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Home My WebLink AboutApplication and WCr � D .. � ►� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/P T� Ol �? DtG �� 7015 : e.,• � � ••- � � � * Please complete form and attach all necess �u�. nts `ce»t� er 1 S 201 S. ' Failure to do so will result in the return r yot:��a�ic�io��*cet. HEALTH DEPT E�TABLISHMENT NAME: v TAX ID: - ' ' LOCATION ADDRESS: i� u ' TEL.#: �= � MAILING ADDRESS: �6 E-MAILADDRESS: Q'2Zq��(?.��,5�'f"/�c"�' OWNER NAME: ' CORPORATION NAME(IF APPLICABLE): , MANAGER'S NAME: 1� �D TEL.#: ' 1VTAILING ADDRESS: ' jL911-f�/�LS POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pbol Operator(s) and attach a copy of the certification to this form. _ _ _ __ _____ _ __ � �;- ---- - --�-- --- . 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. � , i 1. '� Lr� , �/ ? ) 1p 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. "' �l�c�'' �� . �- .�,�_r��.�� --=�_2. ..� 1-s,'.�►�k� �� _ � _ y � �---- _- _—__��_�._ � , r � 4 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. �7�'t.!/`i� � ' �'1L.)��/� 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. i.�/��,�5o ma��ov✓�vs 2._�� ,� �m�� s 3. 4. RESTAURANT SEATING: TOTAL# ,_ __ ��Tr 111�TT v --— -------- -- — --_ ---�-��.E-�F,z��-- _— _ --, LODGING: ' LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' B&B $55 CABIN $55 MOTEL $I10 INN $55 CAMP $55 SWIMMING POOL$1IOea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 � �COMMON VIC. $60 .�tr'I S _WHOLESALE $80 —RES[D.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. $150 _FROZEN DESSERT $40 TOBACCO $110 NAMECHANGE: $15 AMOUNT DUE _ $ 260 •O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �� P � : f 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 ar 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. OFINSURANCE 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. __ ._ _ _ -_ _ _ i 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.�armouth.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 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, 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 REQUIRE A SITE PLAN. I DATE: tj �/� SIGNATURE: � PR1NT NAME&TITLE: < < Jl� � Rev.10/01/15 � ; , ~� � The Commonwealth ofMassachusetts Department of Industrial Accidents Of�ce of Investigations ; ' l Congress Street,Suite I00 '� Boston,MA 02I14-2017 , � www.mass,gov/dia � _ . Workers' Compensation Insurance Affidavit: General Businesses Anplicant Information - Please Print Le�iblv Business/OrganizationName: �2Zct/v �: rl,�/�'!'l�J��1� ��e ��b� ��,�S��t�p� r� ,� Address: ��Q`��'✓�e� _ . � �?�7-3 City/State/Zip: �lyl � Phone#: �1�� f 7�-O�8(� Are you an employer? Check the appropriate bog: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or�art-time).* 6. �estaurantBar/Eating Establishment - — — - --- -- _- --- _ _. _ _ _ _- - _ _ 2. I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto, etc.) employees working for me in any capacity. [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]* 4.❑ We are a non-profit organiza.tion, staffed by volunteers, 11.0 Health Care with no employees. [No workers' comp.insurance req.] 12.❑ Other _ ' *Any applicant that checks box#1 must also fiil out the section below showing their workers'compensa6on 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#L I am an employer that is providing workers'compensation insurance for my employee� Below is the policy information. ! Insurance Company Name:�,t�� p�/Z ��P/� 11�,�T'��C��—,�G• ; Insurer's Address: _ � �j vX� �sg�c�o7-��-�'� City/Staxe/Zip:_f !`Gi%/�i"�� , �- �a7 8� Policy#or Self-ins.Lic.# ��yGU$llr�D� �D//�� Expiration Date: At+frxch a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration datej. ; Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of�. I 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 sta.tement may be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. I do hereby cert�,under the pains and penalties of perjury that the information provided above is true and correc� Si ature: ' Date: c3 �O�v� Pnone#: �� 7�J��j 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 ' I � INFORMATION PAGE RENEWAL AGREEMENT Insurer: PRODUCER: Agent# 932 MA Retail Merchants WC Group Tnc. Dowling & 0'Neil Insurance Agency PO Box 8b9222-9222 PO Box 1990 Braintree, MA 02185 Hyannis, MA 02601 (Carrier Code: 34355) Carrier Policy #: 014005030290115 Carrier Prior Policy #: 01400503029011.4 1. The Insured: Azzaro Yarmouth, LLC The Lobster Boat Restaurant Mailing Address: 681 Main Street Route 28 West Yarmouth, MA 02673 ' Fein: Other workplaces not shown above: Type oE Business: Corporation SEE SCHEDULE OF OPERATIONS Risk ID: ' 2. The policy period is from 12:01 a.m. on 1j01/2015 to 12:01 a.m. on 1/O1J2016 at the insured�s mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each emgloyee C. Other States Insurance: D. This policy includes these endorsements and schedules: WCOOOOOOB(07/11) WC000310(04/84) WC000414(07/90) WC000422A(09/08) WC200301(04/84) WC200302 (05/86) WC200303B(07/99) WC200405(06/O1) WC200601(06/92} 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Rate Per Estimated No. Total Estimated $100 of . Annual Annual Remuneration Remuneration Premium SEE SCHEDULE OF OPERATIONS Total Estimated Annual Premium $ 2,721.00 � � Minimum Premium $ 269.00 Expense Constant .00 Deposit Premium .00 I Client#: 19049 2AZZAROYA DATE(MM/DD/YYYY) ACORDrM CERTIFICATE OF LIABILITY INSURANCE 12/03/2015 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 co�ditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certiflcate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Dowling&O'Neil Insurance Ag PHON� 508 775-1620 F"'� 5087781218 973 lyannough Rd,PO Box 1990 E ANo,eXc: ac,No: ADDRESS: Hyannis,MA 02601 INSURER(S)AFFORCIYG C6VERAGB NAIC# 508 775-1620 iNsuRER A:Mass Retait Merchants Work Camp INSURED INSURER B: Azzaro Yarmouth,LLC A/O INSURER C: Gold Village Waterside,LLC 681 Main Street,Route 28 �NSURERD: INSURER E: West Yarmouth,MA 02673 INSi1RER 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 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 DESCRBEL` HEREIN IS :iUF3JEC" TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS � LTR INSR WVD POLICYNUMBER MM/DD/YYYY MMIDD/WYY GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE �OCCUR MED EXP(Any one person) $ � PERSONAL 8 ADV INJURY $ � �ENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APP�IES PER: �PkODUCTS-COMP/OP AGG $ POLICV PR� LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO �.BODILY WJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ ' AUTOS AUTOS � NON-OWNED . PROPERTY DAMAGE $ �. HIRED AUTOS AUTOS � �(Per accident) _ � i $ UMBRELLA liA6 OCCUR �'EACH OCCURRENCE $ . �— EXCESS LIAB CLAIMS-MADE � '�AGGftEGA"!E _ $ DED RETENTION$ � � $ A WORKERSCOMPENSATION 0140050302901 �1/01/2015I01/01/2016�X WCSTATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE Y�N i �E.L.EACH ACCIDENT 5G'OO OOO OFFICERIMEMBER EXCLUDED? � N/A (Mandatory in NH) � 'E.L DISEASE-EA EMPLOYEE�$SOO OOO If yes,describe under DESCRIPTION OF OPERATIONS below E.i..DISEASE-POLICY LIMIT $�JOO�OOO � � i DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) � Operations performed by the named insured subject to policy conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 'I'I46 ROUt@ ZS ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-4492 AUTHORIZED REPRESENTATIVE ,�� _---�-� O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registsred marks of ACORD #S761813/M161812 LS1 ' i �= � - ,-