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Home My WebLink AboutApplication and WC _� _ � ' � � �,��;.....'�_�,7?ON S � ► TOWN OF YARMOUTH BOARD OF HEALTI� �� " � � APPLICATION FOR LICENSE/PERMI�-2013� �' a�� 12 2(��2 .��O :_ . �y. � ' * Please complete form and attach all necessar�!��.'�D ce . Failure to do so will result in the returti�f y�''applicatio ESTABLISHMENT NAME:�+�.� �S C.w�+�.aq��d �i'1�.InG TAX ID:�� LOCATION ADDRESS:' �;r� S • o�- fi Gp t9 � w�k O�b7STEL.#:SU � ��'�� MAILING ADDRESS: S[.v�{' nn P+ U �! c�� OWNER NAME: o �s "��. CORPORATION NAME (IF APPLICABLE): pt�� S C,�,�m,n,�r v�d �1 n LY,c. MANAGER'S NAME: �.� ce,.S TEL.#: - - .S"0�- MAILING ADDRESS: oz`��'C� ar c�� m Pr � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Po�l Operator(s) and attach a c��y of the certification to this form. 1. 2. 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. 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. _ ��c c/� ��'s b� 2. .11, ,L'!'' D v1 �'EP:��3`v$d CII'��r: __ _ _ _ _ _. _ Each food establishment must have at least ane Person In Charge (PIC) on site during hours of operation. L �%/G��c'� ��6lil 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the I�eimlich 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. /yc ��/ I�r�son 2. �/��.��n �o�rcn � 3.�— 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 _ _CABIN $55 _MOTEL $55 ( INN $55 �/3-00,� _CAMP $55 _SWIMVIING POOL $80ea. _LODGE $55 _TRAILER PARK $105 WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>]00 SEATS $160 J� � � COMMON VIC. $60 ��3 Q�O� _WHOLESALE $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. $225 VENDING-FOOD $25 <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ $ 27 S.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION + r 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 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 OT�-IER L�3D��GIl'�TG ESTABLISH1t�IENTS - 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 De�artment to schedule the inspection three(3)days prior to opening.PLEASE NOTE: People are NOT allowed to srt 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 obtamed at the Health Department,or from the Town's website at www_yarmouth.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: Outsid_e cafes_�i.e.,outdoor seatin�with w�t�x/waitress service),must have priQr approval frQm�Boar�l_ofl3eaLth_ _ 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, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AN APPROVED Y THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY Q I A S P' AN. DATE: SIGNATURE: PR1NT NAME & TITLE: � �-�` ft`1� ��T]�i Rev. 10/09/12 <`�' V� '4CQ� CERTIFICATE OF LIABILITY INSURAN E °"'�`"�'°°""""' �—� C �,�osrro,2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO Rl�iHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATN�LY OR NE(iATIVELY AiNEND, EXTEND OR ALTER THE COVERAtiE AFFORDED BY THE POUCIE8 BELOW. TIq3 CERTIFICATE OF INSURIWCE DOES NOT CONSTITUTE A CONTRACT BETVYEEN THE ISSUING INSURER(S�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTtFICATE HOLDER. IMPORTANT: If tha certlNcate holder Is an ADD�TWNAL iNSURED, the policy(tes�must be endorsed, ff SUBRO(3ATION IS WAIVED,subJect to the terms and conditlons of fhe pu��ay,certa�n po0cles may requlre an endorsement A sts�nt on tlNs csANleaN does not confer Aghts to the certlflcate holder in Ileu ot such endorseme s, PRODUCER � � . � - � Cp�� AME KIRKiLES d�ASSOCIATES �o E •781-659-3380 F �:781-659-3368 COAAMERCWL INSURANCE BROKERAGE�LC 273 RIVER STREET . INsu�R(e �FOROINocw�►oe Hn,�c* NORWELL,tiAA 020612200 u.�sur�a�: MASS RETAIL MERCHANTS IN3URED IN3URER B: ANTHONY'S CUMMAQUID INN,INC. iNsu c: RT.6A iN��a YARMOUTHPORT,MA 02675 r�suRE �: INSURER F: COVERAGES CERTIFICATE NUMBER: 1pQ$51 �g� ��R: THIS IS TO CERTIFI 7HAT THE POLICIES OF INSURANCE USTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABdVE FOR THE POLICY PERIOD INDICATED. N071NRHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIfH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MqY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRlBED HEREIN IS 8t1BJECT TO ALL THE TERMS, EXCLUSIONS AND GONDITIONS OF SUCH POUC�S,LIMITS SHOYVN SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS. �L ��NPE OF'�NBURANCE �� POLICY NUMBER � tJANTB OENERAL LIABILTf . EACM OCf�ICE E COMMERCIAL GENERAL LIABILfTY — a� s CWMS�AAADE �OOCUR MEDEkPlN onepswon S -- PERSONALBADVINJURY i OENERALA00REOA7E i (iEN'L AOC3RE�iAA1'E Llha f APPUE3 PER: PRa0UCT8-COMp/Op/1f3p S POLICY JECT _ LOC : AVI'OM081LE LIA8ILRY a i ANY AUTO 80DILY IN�R/tY ni�t8�'"E° Au4�s°"'.�° �.►v�•�) t pµpyy BODILYNdRlRYIPe►acddenq S HIREO AUTOS AlJr08 N� s : Ui�RELLA UAS OCCUR EACH Of�CU�NCE EXCESB LIAB�'. CLAIM&MADE AOOREGA7E S DED RETENTiqJs MfOR1�R8 COMPENSATqN = A ANDEMPLOYERB��usiunr YlN 0140050310081013 1/1/2012 1/1/2013 X �AMF'PROP EM OR/P��ECUTNE a N 1 A E.L.EACH ACC�ENT S SO��OOO �� E.L as�.�EMPwv� s 500,000 Nye0 deeape untlsr DES�RIPTION pF OPERATION3 E.L DISEASE-POLICY LIMIT S rJOO,OOO DEBCRIPTION OF OPERA710Ns/LOCATIONS!VENICLES(Mh�e1�ACORD 101,Addtlonal R�nrrks soMduls,M mon apw b nqulnd) CERTIFICATE HOLDER CANCELLATION TOWN O�YARMOUTH SHOULD ANY OF THE qgpyE pEg�RlgEp '�_ fE8 gE CANCELLED BEFORE HEAI.TH 1NSPECTOR TME ��TbN DA7E TNEREOF, YVILL BE DELIVERED IN 99 BUCK ISLAND ROAD A��CE WITH THE POLICY pRpWglplg, W.YARMOUTH,MA 02673 FAX:rJOB-7BO-�72 AIP�HORIZEDREPRE9ElITATiVE ��/ .' ncort�2s�2o�orosy �1988-Z010 ACORD CORPORATION. ai��,eservea. The ACORD name and logo are reglstered marks�q�pRp Client#: 395 ANTHONYSFI ACORD.M CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) • 11/16/2012 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 certiflcate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEA T HUB International New England ac"o Ex,:978 657-5100 aC,No: 9789880038 299 Ballardvale St E•MAIL ADDRESS: Wilmington, MA 01887 INSURER(S)AFFORDINGCOVERAGE NAIC# 978 657-5100 iNsuRERA:Public Service Mutual " INSURED INSURERB:HB�IOVQ�If1SUi'ailC@ COI71p811�/ Anthony's Pier 4 INSURER C: Hawthorne By the Sea INSURER D: Anthony's Cummaquid 299 Salem St Swampscott,MA 01907 INSURERE: 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 TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICYNUMBER MM/DDIYYYY MM/DD/YYYY A GENERALLIABILITY CP019145 11/01/2012 11/01/201 EACHOCCURRENCE s1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE 7 RENTED PREMISES Eaoccurrence 550000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ X LiquorLiability ��0�� PERSONAL&ADVINJURY $��0� Inluded GENERALAGGREGATE $Z�OOO,OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $��OOO�OOO X POLICY PR� LOC $ JECT B AUTOMOBILELIABILITY AWN886233800 11/01I2012 17/01/201 COMBINEDSINGLELIMIT EaaccideN . $�,��0,0�� B ANYAUTO AWN8913245 11/01/2012 11/01/201 BODILYINJURY(Perperson) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accidenl) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X rive Oth Car $ A UMBRELLA LIAB occuR UM011456 • 11/01/2012 11/01/201 EACH OCCURRENCE s10 000 000 EXCESS LIAB CIAIMS-MADE AGGREGATE $�O OOO OOO DED X RETENTION$�OOOO $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? � N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.l.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.OISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Evidence of Liquor Liability SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WIIL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE /�K�iG�4�V /w' Ci�'M1�. O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S821303/M819932 MW001