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HomeMy WebLinkAboutApplication and WC C,Ic��l�S(3 - �tSa.00 c,�-f�F�l�f �1co op � �°' TOWN OF YARMOLJTH BOARD OF HE TH r t� '��4;���������� �� APPLICATION FOR LICENSE/PERMi ,��, , �. `` '� *Please complete form and attach all necessary doc '` hyDecember I 20�. �J,�� � � ,���� Failure to do so will result in the return of ya ' pp�i�rat�Qn.pa cet. � �. ����.� � >,. ._. ._ �;��,�'x . ESTABLISHMENT NAME: �'' Ip• - .- LOCATION ADDRESS: R(I'�? TEL.#: MAILING ADDRESS S !/19 /D So2 E-MAILADDRESS: 5� ��/ - 5?0-839 L� OWNERNAME: N�. "r - �e5 ' CORPORATION NAME(IF APPLICABLE): r'2S �prPp L MANAGER'S NAME: I'L TEL.#: - - (p� MAILING ADDRESS. il�R1�J Lj l.LC. � �(.(q� N S� POOL CERTIFICATIONS: `- � r�., 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. 1. 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. L 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: -(�'� All food service establishments are required to have at least one full-time empioyee 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�le 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. i 1. 2. i ALLERGEN CERTIFICATIONS: �' �I ' 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 t31e 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 Heaith Department will not use past years'records. You must provide new copies and maintairr a file at your place of business. 1. 2. , 3. 4 � i RESTAURANT SEATING: TOTAL# � . � ' ' Y OFFICE USE ONLY , LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $110 IA1D1 $55 --- —CAMP $55 -- —SWIMMING POOL$110ea. =LODGE $55 -=I'RAILERPARK $105 _WHIRLPOOL $IlOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REpUIRED FEE PERMIT# 0-100 SEATS $125 _CONT7NENTAL $35 NON-PROFIT $30 _>]00 SEATS $200 _COMMON VIC. $60 __ —WHOLF.SALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 — LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.R. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �Q5,000 sq.ft. $150 �� �ROZEN DESSBRT$40 �TOBACCO $110 �� NAME CHANGE: $IS AMOUNT DUE _ $ k *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINI5TRATION Under Chapter 152,Section ZSC,Subsection 6,the Town of Yaimouth is now rec{uired 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.AFFIDAVTf SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewai 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 therea8er. 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: i Anyone who caters within the Town of Yarmouth must notify the Yarmouth Heaith Department by filing the 4 required Temporary Food Service Application form 72 hours prior to the catered event. T'hese forms can be obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadabie 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 prolribited. ! � 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 EQUII'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: ZQ,Z )� SIGNATURE:—'¢=�.G�1�� � � � j � PRINT NAME&TITLE: r Rev.l0/Ol/IS ''��� DOLLEXP-01 SPRAGUEAN A���~ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YWI� 10/7/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVEIY 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 REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAI.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 CONTACT NaME: Wiilis Certificate Center Willis of North Carolina,I11C. PHONE g77 945-7378 c/o 26 Century Bivd No t:� ) �Na;(888j 467-2378 P.O.Box 305191 �oRess:certificates@wiilis.com Nashville,TN 37230-5191 IN3URER 3)AFFORDING COVERAGE NAIC# iNsuReRa:ACE American Insurance Company 22667 INSURED INSURER B: Dollar Express Stores LLC INSURER C: 7250 E.Independence Blvd.,Suite 100 INSURERD: Charlotte,NC 28227 INSURER E: INSURER 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 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 TYPE OF INSURANCE IN D WVD POLICY NUMBER MM/DO/YYYY MM/DD LIMITS A COMMERCIAL GENERAL I.IABILITY EACH OCCURRENCE $ 'I,OOO,OO CLAIMS-MADE �ocCUR XSL G27401648 10/31/2095 'IO/$'I/2O'IB� pREMISES Eaoccurrence S + 1�000,000 MED EXP(Any one person) $ ����� PERSONAL&ADV INJURY $ ��OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z�OOO,OO POLICY❑�E� a LpC � PRODUCTS-COMP/OPAGG $ Z�OOO�OOO OTHER: $ AUTOMOBILE LIABIIITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ I ALL OWNED SCHEDULED BODILY INJURY(Per acddent) $ � AUTOS AUTOS . HIRED AUTOS NON-OWNED PROPERTY DAMAGE � AUTOS Per accident $ �� �j $ I UMBRELLALIAB OCCUR EACH OCCURRENCE $ f EXCESS LIAB --- -$------------- CLAIMS_MADE AGGREGATE DED RETENTION$ $ --- WORKERS COMPENSATION AND EMPLOYERS'LIABI�ITY X STATUTE ERH /4 ANY PROPRIETORlPARTNERlEXECUTIVE Y�N LR C48594815 10/31/2015 10l31/2016 E.L.EACH ACCIDENT $ �,00�,�� OFFICERlMEMBER EXCLUDED7 ❑ N/A (MandaWry in NH) E.L.DISEASE-EA EMPLOYE $ 'I,UUU,�DU � Ifyes,descrtbe under DESCRIPTION OF OPERATiONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OOO � I I DESCRIPTION OF OPERATIONS(LOCATIONS/.VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) � I I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE � Information Pur ses Onl ���T`-- O 1988-2014 ACORD CORPORATION. All rights reserved. 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