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Home My WebLink AboutApplication and WC � ` ..� { � TOWN OF YARMOUTH BOARD OF HEALTH �� D � � �` �- APPLICATION FOR LICENSE/PERMIT -2012 �� 3,, NOV 15 �011 ; �� * Please complete form and attach all necessary docui�en � Failure to do so will result in the return of y�ap ' f o pac DEPT. ESTABLISHMENT NAME:� /��5��-- TAX ID: LOCATIONADDRESS: 'oZ�I �w� �'h.eru, nr'v�.r TEL.#:�8',3�f�-�-2b�'' MAILING ADDRESS: aRl OWNER NAME: CORPORATION NAME(IF PLI ABL ): L MANAGER'S NAME: r� TEL.#: �'1' � l3�3� MAILING ADDRESS: • � � O' 6' 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. _ 1. '��+-+�� ►'chtt __ .. . 2. �7 ��5�"� Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees 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. ` ( 1. z �� 2 �� 3• 4. c��z�.-��-- 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�le at your establishment. 1. ,� hOmt"k5 2, T �1'f-�� ___-_�FRSON IL�I_�HA� �R'-__--------- --- - - - -- - _ - ---_ __ _- -- _ . _ Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. .. 1. �T�n ,,.�U,,�czlr r�� 2. �f'7,Y�+ �."�/, 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. 1. 2. �i �v�, 3. 4. tL-P RESTAURANT SEATING: TOTAL# 0�.0 5 LODGING: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# _B&B �ss _caBnv $ss I Mo�L $ss �-61 —uvN — »-a r� _ . $55 _CAMP $55 2 SWIMMWG POOL $80ea. _LODGE $55 _TRAII,ER PARK $105 �WHIRLPOOL $80ea. �� O�G� FOOD SERVICE: LICENSE ItEQUIIZED FEE PERMIT� LICENSE REQUIKED FE� PERMIT# LICENSE REQUIRED FEE PEIt1�iiT# _0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30 �>100 SEATS $160 �� COMMON VIC. $60 �l a'� _Wgp�� $80 RETAIL SERVICE: —RE$ID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' _<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 i _Q5,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 i NAME CHANGE: $15 AMOUNT DUE _ � S LS•OO I *****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 CO ENSATION INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIG�IED, OIa � CERT. OF INSURANCE ATTACI3ED . OR i WORKER'S COMP. AFFIDAVIT SIGN�D AND ATTACHED Town of YarmoutYl taxes and liens must be paid priar to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: I YES `� NO M��ELS Ai�1I3� O�I�It�.Q�GII�T��S�A��.ISIiIl�lE1�ITS , 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 OPE1vING:All swimming,wading and whirlpools wl�ich 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. ' i 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. ' FOOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven�7)days of j 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 �ling 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 He�lth 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: �?u+si��€�s-{�..:.s��eer s�at�g��i+.h«r�i�er/�v�:��ss ser��:ce;,:n�as�h��e�r:�a�pr��.�e��of�Ie�?r,�. __ _ __ OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN T�-�COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENC$MENT. RENOVATIONS MAY RE E A SITE PLAN. DATE: SIGNATURE: PRINT NAME &TITLE b�n • e�� Rev.10/25/11 � � , The Comnionwealth of t�fqssuchusetts ' Departnrent of Indastria!Accidents , , � N�feiNfrr�;�iNf� 600 Washington Street, f"'Floor Bostoa,Mas� 02111 ' Workers'Compensatioa Insaranee AfBdavit. gnilding/Piambiag/Ekctrica�Coetractors ; ��t I�fi.�e��tM�- Please PRINT kQlbh . namc: acidress• i -------_._...----------- -- ( cirv � state• � � zio � � � � nhcwr# � wnrk site Iceation full addcess: � I am a homeowner perfom�ing all work myself. Pro ect T 1 � .I YPe� ❑New Constn�ctioa�Remodel { ❑ I am a sole proprietor and have no one wocicing in any capacity, �gw��g Addition � �I acn an employer providing workers'compensation for my employees working on tliis job. i � �� .,�m�: Blue Water LP : ._ , . ...-.�. , -- . $� � �aar�s: 20 North Main Street �ic�: South Yarmouth, MA 02664 �,�* 508-398-2293 t��a.oe�a Zurich American Ins. Co # WC8196036 ❑ [am a sote proptietor,geseral co�tractor,or Iromeowner(circl�on�)and have hired the contcactocs listed below who have � the foilowing workels'compensation polices: I � �ro i � address: city: . . DbOs!/{ . . . iBaa�aace co. odic►# —�____.___ address- city- ulo�e N i� �, � _ _ .. , _ AWe�ad�Y tlyd Ktre�s� Faihre o�xeare carva�e n reydn+d�edv SecMs�2SA�t MGL 132 eu le�d b tre��[�d . °k Yb�'1e�ei�oaemt as wdl as dv�peealtlea la t6e firi e(s 3TOr WORK ORDER asd�Aee d f1d0.0��a da�•f a A�e�p b 21,3M-M ud/�r npy�[trh�tahment m�y be forwarded es tAc Odice e[Iwe�tl�tls�of t6r DIA tor crersae�^erlQeatlN. Y��tse. 1 aedenCud that a I do 6er+eby ce wnder Nfie pe�ws as oldes ofPerfWry'tket tlYt Jwforiwalloe provlded aboae Ls dwe aw co Signatua 'f / Date I� � �� Print narne�j"IarV pL,rrie�, as agent only Phone�k SOH-398-2293 offkW ax edy do eot wrMe h�this�rea to Ae ce�pieted by cky or�wo oHkLi -, dty or tawu- � PermiN�ense� QBaidloa Depar�ent � p c�ed�Kim�eedf.ee r+�peme is reqdnea Oueee�ia�Bo.ra (�3deetmn's(lf�oe rnntad penoo: QHpNi De�� ,�� p6oee Il; Ootber !'�� OP ID:EE AC�O-R�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYW) 02/24/11 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 certiflcate holder in lieu of such endorsement s. PRODUCER 610-279-8550 NAMEACT The Addis Group,Inc. 610-279-8543 PHONE Fax 2500 Renaissance Blvd.Ste 100 Evc o Ext: A/C No: i King of Prussia,PA 19406-2772 E•�^�� ; Jeffrey A.Grebe PRODUCER � M R io#:DAVEN-1 INSURER S AFFORDING COVERAGE NAIC# INSURED g�ue Water LP INSURERA:AIII@�IC811 ZUflCII IIISUI'8flC@ CO. 40142 c/o Davenport Realty Trust ir,suReRe:Zurich American Insurance Co. 16535 Stephen Aschettino INSURERC: 20 North Main St. South Yarmouth„MA OZB64 INSURER D: 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 7ypE OP INSURANCE ADDL SUB POLICY EFF POLICY EXP LTR POUCY NUMBER MM/DD MM/DDIYYYY ��M� GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO,OO B X COMMERCIAL GENERAL LIABILITY GL08196255 03/01/11 03/01/12 pREMISES Ea occurrence $ 500,�� CLAIMS-MADE �OCCUR MED EXP(My one erson) a 10,�� PERSONAL 8 ADV INJURY a 1,000,00 GENERALAGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POUCY PR� LOC E AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ �,OOO,OO B ANYAUTO BAP$'I9GLSB 03/01/11 03/01/12 �Eaacadent) BODILY INJURY(Per person) 8 X ALL OWNED AUTOS BODIIY INJURY(Per accident) $ SCHEDULED AUTOS X HIREDAUTOS (Pe�cGd nt)AMAGE a X NON-OWNEDAUTOS $ X 250 Comp a UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS IJAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE a RETENTION $ f WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY � � A ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N WCH�9GO36 03/01/17 03/01/12 E.L.EACHACCIDENT $ ��00 OFFICERIMEMBER EXCLUDED9 � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addldonal RemaAcs Schedule,ff more space Is requlred) CERTIFICATE HOLDER CANCELLATION YARMO-0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE 7HEREOF, NOTICE WILL BE DELIVERED IN ROUte 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATNE T�� O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD