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Home My WebLink AboutApplication and WC � � T�� ! , TOWN OF YARMOUTH BOARD OF HEALTH ', � � APPLICATION FOR LICENSE/PERMIT -2016 `"' * Please complete form and attach all necessary doc}�rr�ents by December 1 S, 201 S. ' Failure to do so will result in the return of�iu�r pplica�r�packet. � l/ E5TABLISHMENT NAME: �1�. T ID: LOCATION ADDRESS: � �1 � L•#: MAILING ADDRESS: �' C' � �- � E-MAIL ADDRESS: � �' . OWNER NAME: �'- ' CORPORATION NAME (IF PLIC LE): MANAGER'S NAME: U TEL.#: MAILING ADDRESS: � � � PbOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. lea��nat d Pool Operator(s) and attach a copy of the certification to this form. ; . at� � + 70�� ; - � ____ _ _ ___ _ _ . __ -- - -.-_ - -- -- ._ _ _ 1 _ _ _ _ _ _ H,EALTH DEPT. Pool operators must list a minimum of two employees currently certified in standard F � 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. , l. 2• 3. 4. i 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 CHAR E: 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�efined in the State Sanitary Code far 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.� I�D � 2. �� HEIMLICH CERTIFIC TIONS: ! 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�le at your place of business. : 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# i � ; ---__ ----- ----- ----- -�r� ' 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 $1 l0ea. FOOD SERVICE: L�CENSE REQUIRED FEE IT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 ��7 CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 I _<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ � ISSrOO *****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 AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR , i � 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 � f 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 customaxily 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. '! i 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 obtained 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 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. ,- _—_ . __._ __�___..�___.__..�._ DATE: r 2- �o .- 2v j s SIGNATURE: �-��. - _ PRINT NAME&TITLE: � V t- ' Rev.10/01/15 r � The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations ' f 1 Cong7ess Street, Suite I00 _ Boston, MA 02114-2017 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: General Businesses � Applicant Information Please Print Legiblv ; Business/Organization Name: � , � �/��2 , Address: `� 2 �'� �'(� '��'�° City/State/Zip: Phone#: Ar,�e y,/o�'an employer? Check the appropriate bog: Business Type(required): 1.I�' I am a employer with employees(full and/ 5. ❑ Retail " � _ _ __ or part-time .* 6. ❑RestaurantlBar/Eating Establishment � _-- --- — -- -- - 2. I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl.real estate,auto,etc.) ; employees working far me in any capacity. [No workers' comp. insurance required] 8• ❑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 warkers' comp. insurance required]* 4.❑ We are a non-profit organization, staffed by volunteers, 1 l.�Health Care with no employees. [No warkers' comp. insurance req.] 12.0 Other � i *Any applicant that checks box#1 must also fill out the section below sbowing 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#I. i I am an employer that is providing workers'com ensatiqn in uranc for my employees. Below is the policy information. ' Insurance Company Name: `��. �� /� � ' ��,� i Insurer's Address: ' City/Sta.te/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 lea.d to the imposition of criminal penalties of a -- -— -- -- - fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the orm o a O�'W��i�(�k�UU�k an�i 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 penalties ofperjury that the information provided above is true and correc�t. Si ature: Date: f 2 � � '�l� ', Phone#: ' Official use only. Do not write in this area,to be co►npleted by city or town officiaL f 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 AC Q� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 1/5/2016 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 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). PRODUCER N NAME: MCSHEA INSURANCE AGENCY INC PHONE F� ' 1550 Falmouth Rd Ste #2 ac�No eX�: (508)420-9011 ac No:(508)420-9010 nooRess:michele2@mcsheainsurance.com Centerville, MA 02632 PRODUCER STOMER ID#: INSURER(S) APFORDING COVERACaE NA�CM INSURED Jerk Cafe, INC INSURERA:Ndt].OAdl GI'dIICjE Mutual Ins Co. Glen Roy Burke ir�suReR e:The Hartford Insurance Company 39 Joe Lincoln Road INSURERC: West Harwich, MA 02671 INSURERD: INSURER E: 4NSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE JNSURED 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. INTR TYPE OF INSURANCE � A�� SUBR LICY FF POLICY EXP � � INSR wvo POLICY NUMBER MAA/DD/YYYY MMlDD/YYYY � LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1� O O O�O O O X COMMERCIAL GENER,4L LIABILITY PREMISES Ea occurrence $ 1� O O O,O O O ICLAIMS-MADE C)OCCUR MED EXP(Any one person) $ 1�� A BP03066J 8/10/158/10/16 PERSONAL&ADVINJURY $ li �D�s�Q� GENERAL AGGREGATE $ 2�O O O�O O O GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2�O O O�O O O POLICY PE� LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANYAUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ � � � NON-OWNED AUTOS g $ UMBRELLA IIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE ' $ RETENTION $ $ ' WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y�N X TORY LIMITS • ER B ANY PROPRIETOR(PARTNER/EXECUTNE � �0 8WECCN07 4 0 6/2 6/15 6/2 6/16 E.L.EACH ACCIDENT $ 5�0 i 0 0� �� OFFICER/MEMBER EXCLUDED? N�A 5 O O O O O (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ i Ifyes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ �J O O, O O O D DESCRIPTION OF OPERATIONS/LOCATIONS/VEHIC�ES (Attach ACORD 101,Additional Remarks.Schedule,if more space is required) t�i».. �.7 E.�.��J CERTIFICATE HOLDER CANCELLATION ' Board Of Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Route 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W ' South Yarmouth, MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. ' AUTHORIZED REPRESENTATIVE J'��Cc�� OO 1988-2009 ACORd CORPORATION. All rights reserved. ' ACORD25(2009/09) The ACORD name and logo are registered marks of ACORD