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Home My WebLink AboutApplication and WC �. �� ► TOWN OF YARMOUTH BOARD OF HEALTH ��° ��$ ; � APPLICATION FOR LICENSE/PER�I R �- 0 ��,�; ��::i �; � 1�� "'°" * Please complete form and attach all necessaty i�ocu.,, , � ` 1 S 201 S. a Failure to do so will result in the return�a�yoti'��ication pack H DEPT. E�TABLISHMENT NAME: =I-?� TAX ID: ', LOCATION ADDRESS: �� .�. S�Y.:2 17 Y�v�2 TEL.#:�O$ ��3� 2(0�� ' MAILING ADDRESS:2S5 1a�c�, o L�o�r; M;�dc��n , 121 OZS��2 ' E-MAIL ADDRESS: 1v / �1 OWNER NAME: C�Cocarn NVIS-� � L_-L.L ' CORPORATION NAME IF APPLICABLE): ' MANAGER'S NAME: -� TEL.#: OI 2 �SS MAILING ADDRESS: l 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-_—___�_ _ _ 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � � , 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 f provide new copies and maintain a file at your establishment. ' 1. 2. HEIMLICH CERTIFICATIONS: A11 food service establishments with 25 seats or more must have at least one employee trained in the Heimlich I 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. q,, f i RESTAURANT SEATING: TOTAL# j � -- ------8��'+�� 1 - - -- - , LODCING: j LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P IT# � _B&B $55 CABIN $55 1MOTEL $110 � I� CAMP $55 2 SWIMMING POOL$110ea. �� 06� ' _LODGE $55 _TRAILER PARK $105 �WHIRLPOOL $110ea. � FOOD SERVICE: 4 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 yWHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 _>25,000 sq.ft. $285 VENDING-FOOD $25 ' _<25,OOOsq.ft. $I50 _FROZENDESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ y�Q,� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � � 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 i AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED ✓� OR i , 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 ofthe limitations of�Vlotel or Hotel use,Transient occupancy sha11 be 4 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 def ned 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 i 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 Deparhnent 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.yarmouth.ma.us under Health Department, Downloadable Forms. FRQZEN 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 �I 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, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISH T, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND PROVED BY THE BOARD OF HEALTH PRIOR , TO COMMENCEMENT. RENOVATIONS MAY RE A SITE PLAN. ' DATE: �4 G� SIGNATURE: � PRINT NAME &TITLE: J� Rev. 10/01/15 � � The Commonwealth ofMassachusetts Department of Industrial Accidents ', ' � Office of Investigations � ' ' I Congress Street, Suite 100 ' Boston,�IA 02114-2017 � _: www.mass.gov/dia ; Workers' Compensation Insurance Affidavit: General.Businesses ,,: "' . _ . � ... ��_. Auplicant Information Please Print Legiblv _„ � �`� Business/Organization Name: Q S-� �C�1 � � �U�� Address: �� - �. ��`��(1 v-'� City/State/Zip: �- r � Phone#: �Q� 3�� 2(o�� Are you an employer?Check the appropriate box: Business Type(required): , 1.�am a employer with�employees(full and/ 5. ❑ Retail ' _ or part-time�.* 6. ❑ RestaurantBar/Eating Esta.blishment - - - — ---_ _ _ - — - - 2. I am a sole proprietor or partnership and have no � -- � ; 7. ❑ Office and/or Sales(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]* 11.� Health Care � 4.❑ We are a non-profit organization, staffed by volunteers, i with no employees. [No workers' comp. insurance req.] 12.[�6ther ' *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 provdding workers'compensation insurance for rrry employees Below is the policy information. i Insurance Company Name: �LV�"\L� ��j�--�1'�n ��`� Insurer's Address: I �UC�C� �v�� c�� .v� Q City/Staxe/Zip:_�� C�_�J V�(1 Y, )L� �1 1 S �- ��` �� - ; Policy#or Self-ins.Lic. # l�t�� )1 �� t��` Expiration Date: �� I � � � �� 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 ' — =—----- _____ fine up to$1,500.00 and/or one-year imprisonment,as well as civ�pena�.tie�' s in the�rin o a RK�RISER and a�ine � of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. ; I do hereby certify,under the pains and enalties of perjury that the information provided above is true and correct. � Si ature: � Date: � Phone#: i ; Official use only. Do not write an this area,to be completed by city or town officia� ( � City or Town: Permit/License# � Issuing Authority(circle one): I i 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office � 6.Other Contact Person• Phone#• wwwmass.gov/dia �I I � J+��1 � f AC�R� DATEIMM/DD/YYYY) �,, CERTIFICATE OF LIABILITY INSURANCE 3/24/2016 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 POUCIES 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 certlficate 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 requlre an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. � PRODUCER NONTACT JENNY FERREIRA � GENATT V LLC P"o"E ,516-869-8666 F"X .516-706-3327 3333 NEW HYDE PARK RD SUITE 400. E'""^"- .jennyf@genatt.com NEW HYDE PARK NY 11042 INSURER S AFFORDING COVERAGE NAIC# �NsuReRn:Zurich North Ameriea INSURED NEWPHOTE INSURER B: NEWPORT HOTEL GROUP LLC, ETAL INSURERC: 280 JACOME WAY INSURER D: MIDDLETOWN, RI 02842 INSURER E: INSURER F: C VERA E C TI I AT N AABER: 1491143551 REV N N MBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH 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 POLICY EFF POLICY EXP LTR TVPE OF INSURANCE POLICY NUMBER DD MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGET RENTED CLAIMS-MADE OCCUR PREMI E Ea accurrence $ MED EXP(An one erson) $ PERSONAL&ADVINJURY $ GEN'L AGGREGATE 1IM17 APPLIES PER: GENERAL AGGREGATE E POUCY PRO- . .. . JECT �LOC PRODUCTS-COMPlOP AGG $ OTHER: $ AUTOMOBILE LIABIUTY $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS NON-0WNED PR PER DAMAGE AUTOS Per accident $ $ UMBRELLALIAB pCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTION$ $ q WORKERS COMPENSA710N VVC014008001 11/15/2015 11/15/2016 PER OTH- AND EMPLOYERS'LIABILITY Y�N TATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACHACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED9 � N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/IOCATIONS/VEHICLES (ACORD 101,Addido�al Remarks Schedule,may be attached if more apace is requlred) � AS RESPECTS HARBORVIEW HOTEL INVESTORS LLC,213 OCEAN STREET, HYANNIS MA 02601 AND OCEAN MIST LLC, 97&73 SOUTH SHORE DRIVE, SOUTH YARMOUTH MA 02664 CERTIFICATE HOLDER CANCELLATION 30 DAYS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEILED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE TOWN OF YARMOUTH BOARD OF HEALTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 ROUTE 28 ' SOUTH YARMOUTH MA 02664 pUTHORIZED REPRESENTATIVE I ,��'-�� O 1988-2074 ACORD CORPORATION. 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