HomeMy WebLinkAboutApplication and WC . , *
�:. ._
��rW�
TOWN OF YARMOUTH BOARD OF HEAL� `�^� 'G�3 C C�CS D�I C�L, �
APPLICATION FOR LICENSE/P��'�.2010 ;
��-0 to,�� � N V 2009 �
*Please complete form and attach all necessary�do�um�t�-liy'7�ece er 1� ��.
Failure to do so will result in the teturn of�ur apphcatton pa DEt�i�. �
NAME OF ESTA�LISHMENT: ^� L,?G:-�, TEL. ����Q 8�2���
LOCATION ADDRESS: 4 ..5`
" MAILTNG ADDRESS:
OWNER NAME: `�+f ct� r E or S
CORPORATION NAME �IF APPLI A�E): 1;,} ti �s�./�
MANAGER'S NAME: cs h Cri TEL. # ''7�7'�j�o�'r /,;3�s�
MAILING ADDRESS: �
r ►�vu Q�6!
POOL CERTIFICATTONS:
The pool supervisor must be certified as a Pool pperator,as reqnired by State law. Please list the designated
Pool O,perator�s) and attach a copy of the certification to this form.
� � � � — � __ - ---
1. ':�"�'� I�C��' �� �� 2.
y : �
Pool operators must list a minimum of two employees currently certified in basic water safety,standard Fixst Aid and
Conamunity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies of employee
certifications to tlus form. The Health Department will not use past years' records. You must provide new
; copies and m�intain a �ie at your place of business.
1._�L �/' ,
in_ N�°/'i� 2. D d�
3. 4.
' �__..�_.r....�,._�.._�., __._�.. �
i
i FOOD PROTECTI�N�VIANAGERS - 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 Faod Service Establishments, 105 CMR 590.000.
Please attach copies of certificarion ta this application. The Health Department will not use pAst years'records.
' You must provide new copies an�d maintain a file at your establishment.
i
� ,� a
� 1. r� � , 2. .__l[5�ti ,�'- �s-�.�
� � .
PERSON IN CHARGE:
_ _- - ---
____
,
Each food establishment must have at least one Person In Charge (PIC) on site during hours o£'operation.
1. .1°l,� •°� �� 2. /? � e�/�.
,.__,.�
HEIMLICH CERTIFICATIONS:
All food service establishments with 2S seats or more must have at least one employee train�d in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anri-chakuig 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���' .
3. 4 ��- ''r ,
� RESTAtJRA,NT SEATING: TOTAL# ,f�4'
i
�
LODGING: OFFZCE USE ONLY
; LIC�NSE REQTJIRBD FEE pEgM,IT# LICENSE,REQUIRED FEE PERNIIT# LICENS�REQUIItED FEE PERMIT#
I
� ,_,_B&B $55 �CABIN $55 I MOTEL $55 � p-O(
� — --�"F�;�________--_ $55 -�c0-o2�
_.._C�`�-° _--- �55 2 SWIMNrIt?�GPOOL �80ea. �t0�oZ7
__,_LODGE $55 �'TRAILERPA.TtI{ $105 � WHIR,I,,POOL $80ea. IO-Ol
FOOD SERVICE:
+ `_. LI�:�TS�TZEQiJIRET? FEg I��R1�jIT# LICk�1SE REQUIRED F�E PERMIT# � LICENSE REQITfRED FEE PERMIT#
i `0-100 SEATS $85 _CONTINENTAL $35
�NON-PROFIT $30
I >100 9EA'TS $160 `�t /O..h4� I COMMON VIC. $SO �{- 0-03 WHOLESAL� $80
RETAIL SERVICE: �
—.RESID.KITCHEN �80
LICENSE R�QUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LIC$NSE REQUIRED FEE PERMIT#
_,,,,,<50 sq.ft. �50 i>25,OOQ s .R. $225 �
q VENDING-FOOD �25 I
„�Q5,000 sq.ft:' $80 .�FRQZEN DESSERT $40 �
TOBACCO $55
NAME CHANGE: $is AMOUNT DUE _ $ 5 I S.00
�
"*""*�LEASE TURN OVER AND COMP'LETE 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 pernrit to operate a business if a person or company does not have a Ceitificate of Worker's
Compensation Insurance. THE ATTACH�D STATE WORKER'S COMPENSATION YNSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR ;
;
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior o renewal oi issuance of yaur permits. PLEASE CHECK
i
APPROPRI�4TELY IF PAID: �
yES NO
MOTELS AND OTSER LODGING ESTABI.ISHMENTS ,
;
TRANSIENT OCCUPANCY: For putposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be �
limited to the temporary and shart term occupancy,ordinaril�and customarily associated with motel and hotel use. �
Transient occupants must have and be able to demonstrate that they mairnain a principal place of residence eLgewhere. �
Transient occupancy sha11 generally refer to corrtinuous occupancy of nat more than thirty (30) days, and an
aggregate of not more than ninety(90) days within any six(6)month periad. Use of a guest urut as a residence or
dwelling unit sha11 not`be considered transient. Occupancy that is subject to the collection of Room 4c.cupancy `
Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as�nended, sha11 generaUy be coii�ider�d Tfansie�rt. ' �
POOLS
POOL OPENING: A11 swimming,wading and whirlpools which have been closed for the season must be ins�ected
by the Health Department prior to opening. Contact the Health Department to schedule the inspectionthree(3)days
pnor to operung.PLEASE NOT�:People are NOT allowed to sit in the pool area until tl�e pool has been mspected
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
CATERING FOLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Departme,nt 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.
FRUZEN DESSERTS:
Frozen desserts must be tested an a monthly basis by a State cert�fied lab. Test results must be sent to the Health
Department. Failure to do so will result in the suspemsion or revocatio� of your Frazen Dessert Permit untit the `
above terms have been met. ;
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seatin�with waiter/wa,itress servic�),must have prior approval fromthe Board ofHealth.
pUTDOUR COOKING:
Outdoor cooking, re aration,or display_of an�food pro_duct by a retail or food service e�ta.bli�h�ent is prohibited._____ -
NUTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.ITY TO RETURN i
__ THE COMPLETEI'�RE].�E'�VAI,�"PLICA�I�I.�(5)Al�1���ED FEE(S)BY DECL�'MBER�I�,��9.�.
ALL RENC>VATIONS TO ANY FOOD ESTABLISHMENT, MOTEL UR POOi.�(�i.e.O, PA►IN'f1NGP� i
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPR4VED BY TI-�B4 ;
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. �
�
� SIGNATURE: � �
DATE: ,
PRINT NAME&TITL . � r'
09l25/09
ti�_
c , �.-r., + .
: � �
The Co�nmoawealth of Massachusetts
Department of Industrial Accidents
N�C'IIf�/�
600 Washington Street, 7`"'Floor
' Baston,Mass. 02111
' + Workers'Compeasation feseranee Af6davih Baildiog/PlembinglEtectrical Coatractors
; �r f�f�+�.�..• Pie„e pRUVT te�bl.
name:
addtess:
citv
. - Si3lC' � Z1D D�IODC�
work sit Location full address: `
� I a homeowner perforniing all work myseif. Pro'ect T
❑ am a sole J YPe= ❑New CamsKruction QRemodei
P�'oPnetor and have no one working in any ca�city. [Q Building Addition
— I am an employer providing workeds'compensation for my employees wo�cing on this job.
� �m .ame: ��u e��'d t`�T�"�,�. _ ,�
�a�: 20 North. Main ,Street
�c�: South Yarmouth, MA 02664 ���,; 508-398-2293
j , �"- : can Ins Co WG8196036
� �_ ,� ..
� ❑ I am a sole proprie,for,geeera!coatractor,or bomiaeewner(cirde one)and have hired the _��� �f,�� :�%�����:�� . ��'.�V
We following workers'co �tors listed below who have
� mpensation polices:
address:
dtw
n4ose i�
i�saatae es.. .
� n � # .
. . . -� �:;,� �,:�:?•' `��;:-
ad�ess:
�9: .: :
!� .
i, _ _ _ —. —. -------- :
- -- - -- -- ---
.. {79. . . . . . . . � . . . .
'
-,.' .. � .... . .. , ;.. . . . � --.__ _ . . --�-- ----- — -
� � -�-' �.:r� ,,.�. . .... .. :.,. . . . — -- . - . ___.. �
.. . . . '. .. . ... �- -
Fa�me a uc�re er�era�e a�rc9drod a�d�Satloi iSA�t 1►!GL�13,2 ca�k�d ta��'• ���_ �....�} ��;�' �1„ :-.���;���°�r::�
°K Y�+s'�ptite��est a�wea as dH pe�IHp it tie forat�ta 31'Or WOItK ORDER��e a[fi1N,N��f a�e�p b�i,sM,N aid%r��
�p7'���my be fit'warded M Ne O�ee�[it�KIYe DIA tr a�raae�np�, �Y�me. 1 asder�ard t0�a
I Jo bd+eby der dFe peius�ed ' ofptryiirry dU�t tbe lw
_ 1��++provide�aboae is a�xe wwd oenrct
SiBn�une
. n�u � � -� R-�nnA
�ri�name N1a��v PtirriPr� aG agent onlv Phoae# 508-398-2293 '
�dai ax w1y do wat write f�t�s ar�ea b be n��iefe�b7.dt�'K tpR,�1 -
ekj'�r bwa: ;. .
� : �itlioease 1'
0 c�edc if Lea�edhte re�psase is reqsi�+ed n�goand t
��� j
� �� .
c�a� pt.ee 1�; �--�,
�
_ _ �
OP ID J DATE(MMIDD/YYYY)
AcoRD CERTIFICATE OF LIABILITY INSURANCE DA�-1 03 06 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE
The Addis Group, Inc. HOLDER.THIS CERTIFlCATE DOES NOT AMEND,EXTEND OR
; 2500 Renaissance Blvd. Ste 100 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
� King of Prussia PA 19406-2'772
� Phone: 610-279-8550 Fax:610-279-8543 INSURERSAFFORDINGCOVERAGE NAIC#
� INSURED INSURERA: Iwrican Zurieh Zasuraac� co. 40142
B UE Water � INSURER 8: susieh 7wricsn Iasusane� co. 16535
J c o Davenport Realty Trust INSURER C:
� S e hen Aschettino
Sout�h YarmaouthStMA 02664 �NSURERD:
� INSURER E:
! COVERAGES
THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN�SSUED TO THE�NSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TEqM OR CONDRION 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 SUB.IECT TO ALL THE TERMS,Q(CLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POL�Y NUMBER DATE MMIDDN DATE MNUDD/Y ��TS
GENERAL LIABIL.ITY EACH OCCURRENCE $1�OOO�OOO
$ }� COMMERCIALGENERALLIABILITY GLO8196255 O3fO1�O9 O3�OZ�ZO PREMISES Eaoccurence $SOO����
CLAIMS MADE �OCCUR MED EXP{Arry one person) S 1 O�OOO
PERSONAL&ADV INJURY E 1�OOO�OOO
� GENERALAGGREGATE $2�OOO�OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E Z�OOO�O OO
POL.�CY PRO-
JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMR
B ANYAUTO BAP8196256 03/O1/09 03/O1/10 (EaacGdent) S 1�000�000
X ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
X HIRED AUTOS BODILY INJUflY
X NON-0WNED AUTOS (Per acddent) $
X 25O COIRj� PROPERTY DAMAGE
X r'JOU CO].1 (Peraccident) a
GARAGE LIABILiTY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSNMBRELLA LIABIUTY EACH OCCURRENCE $
OCCUR �CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETE�fTION $ ' S
WORKERS COMPENSATION AND X TORY LIMITS ER
A �P�ov�as•uasiurr WC8196036 03/01/09 03/Ol/10 E.LEACHACCIDENT $1,000,000
OFFICER/ME BER XCLUDE�ECUTIVE E.L.DiSEASE-EAEMPLOYE $1�OOO�OOO �
If yes,describe under
SPECIAL PROVISIONS below E.L DISEASE-POLICY LIMIT $1 OOO OO O
OTHER
i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS
� �
I
i
I
CERTIFICATE HOLDER CANCELLATION
YARM�-2 SHOULD ANY OF THE ABOVE DESCRiBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING MSURER WIIL ENDEAVOR TO MNL 3O DAYS WRITTEN
TOWl1 Of YdZ1[1011ti1 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEPT,BUT PAILURE TO DO SO SHALL
Attn: Permit Dept WIpp3E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE MISURER,ITS AGENTS OR
1146 Route 28
S. Yarmouth, MA 02664 REPRESENTATIV .
AUTH SENTATIV
4
ACORD 25(2001/08) �ACORD CORPORATION 1988