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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH Q��° � � APPLICATION FOR LICENSE/PERMiT-2010 �� , . �� o�c � ; - a *Please complete form and attach all necessary documents by Dece er 0 ut�-�- Failure to do sa will result in the return af your application pac e . NAME OF ESTAI3LISHMENT: � TEL. #,��4•�6�- '�'•S'o� LOCATION ADDRESS: � ' , I�- MAILING AADRESS: ��.,�,� OWNER NAME:,�r ,r,�,.�rt-�t„�,h,=- � TA�ID (FEIN or SSN)� CORPORATION NAME (IF APPLICABLE): � MANAGER'S NAME: TEL. # MAILING ADDRESS: �o v+� c POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Qperator,as required by State law. Please list the designated Pool Operator(s) and attach a co�y of the certification to this form. l. 2. Pool operators must list a minimum of two emp loyees currently certified in basic water safety,standard First Aid and Community Cardiapulmonary 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. �. a. 3. 4. FOOD PROTECTION�IANAGERS - CERTTFICATIONS: 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 Establishrnents, 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. �tLi�c� Wc f.3�h 2. m PERSON IN CHARGE: Each food establishment must have at least one Perso�n In Char�e (PIC) on site durin�hours of operation. l. �� c�/ ��.sQril 2. m 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-chokmg procedures below and attach copies of employee certificarions to this form. The Health Department will not use past years' records. Yon must provide new copies and maintain a �ile at your place of business. 1. �� c,�� 2. /ycr�'a ��-�.r,� 3. 4.� RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQLTIRED FEE PERMIT# �B&B $55 (O"O� _CABIN $55 _„MOTEL �55 I INN $55 �CAMP $55 �SWIMMtNG POOL $80ea. �LQDGE $55 �'TRAILERPARK $105 �WHIRLPOOL $80ea. FpOD SERVICE: LICENS�REQUIRED FEE PERMIT# LICENSE REQUIRED F�E PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $85 _CONTINENTAL $35 �NON-PROFI'� $30 �>1005EATS $160 ��`�� COMMONVIC. $b0 � O�a� �WHOLE3AL� $80 RETAII.SERVICE: —RESID.KITCHEN �80 LIC�NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC$NSE REQUIRED FEE PERMIT# �<50 sq.8. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 „��25,000 sq.ft. $80 ,_FRQZEN DESSERT $40 TTOBACCO $55 NAME CHANGE: $is AMOUNT DUE _ $ ;�� '`� � "**""PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""*"** � ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal of�ny license or p�mut to operate a business if a person or company does not have a Certificaxe o£Worker's Compensation Insurance. THE ATTACHED STATE WURKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANGE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your pernaits. PLEASE CHECK APPROPRIATELY IF PAID: / YES ✓ NO MOTELS AND OTAER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitatians of Motel or Hotel use,Transient occupancy sha,ll be limited ta the temporary and short term occupancy, ordinarily and custornarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maixrtain a principal place ofresidence eLsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirry (30) days, and an aggregate of not more than tinety(90) days within any six(6)manth period. Use of a guest unit as a residence or dwelling unit sha11 not be considered transient. Occupancy that is subjeet to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shail generally be consid�red Transient. POOL5 POOL OPENTNG: A11 swimming,wading and whirlpools which ha.ve been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Departmertt to schedule the inspection three(3)days pnor to operung.PLEASE NUTE:People are NOT allowed to sit in the pool azea untal the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,tatal coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to openin�, and quarterly thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('7)days af closing. . FOOD SERVICE CATERING FULICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Depaztment by filing the required Temporary Foad Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department. FROZEN DESSERTS: Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent to the Health Department. Failure to do so will result in the susper�sion ar revocation of your Frazen Desse�rtt Permit untit 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 ofHealth. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail ar 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, 2009. ALL RENOVATTONS T(3 ANY FOOD ESTABLISHMENT, MOTEL OR POO�, (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY TT-�BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIUNS MAY REQUIRE A SITE PLAN. DATE: /.� ..�� o SIGNATURE: �� _ �-�"'— PRINT NAME&TITLE: o 09!25/09 • � The Commonwealt/t of Massachusetts Departine�t of Industrial Accidents N�c�Mrw�StMl�f 600 Washington Street, 7`"'Floor Boston,Mass. 02111 Workers'Compeosallos[asaraace piRdavit;gaiidiog/plombi�g/Ek�ctricat CoOtnctors P'kaae PRIPIT leplbl� name: �/nf�i�ni��-1 Lr��irsee��-C►�? addcess• �j� �j9 l�s�r/'MO[JTt9�d r�� state• /7G zip�.2� oh�e# �I�,,�7-�'��7�2o I work site location(fiill addressl: ❑ I am a homeowner performing all work myseif. Project Type: ❑New Constructia�[]Remodel ❑ I a sole pro�ietor and have no one working in anY�P��h'• ❑Building Addition I aum an empbyer providing workers'compensati�f�my employees working�this job. comaaev.ame• �i,�,t�� s� u/�� address• � .n �� : �t�do,�f �1� �� -�s �,sz ys�a� �. • � � ❑ I am a�le P��r,��o��tor,or tiomeo�►wer(circle o�)and have hirad tbe cantractocs listed below4w��_. = the follow�n wotkers'co ho have �onanv iaQe: addrrs• citv �� ius �ct � F_� ., , _,,, s «e.;. ��a��aoe: addras: cltv- oro�e�t . _ � �.. ; „ . . .t,i, '�• ��\ �:�.� ` K Yq(-:�'� :�_ ..'; I K.ctz, .,�.,, FaY�t+e/a ta�e n� �ea";;. v o�v�e ee9�hed�adv See1M�2SA�t MGL 132 eu le�d N tl�e d vl�lul pnaNks d a�e�p b i1.SN�M aadlK e�e y�nn'Ie�M�woeat a�wd as dH pnaltla h tie twn K a STOt WORIC ORDEA ud a ece�!i1M.M a dar�t se. I odersd�d t�a c�pg�t tih�tatemeM'ay be f�rwarded b Ne Omce�Uavatlptlw�t t4 DIA hr arerase v�ee�eatlN, /ro I Fertiby certtjy reder tbe palwJ awr pewdHes o ywry tA�it tlYe iaforar�tion p�vided abope h lrre iw�onn+ert S'gnatuce� � �-,�-u.�`"�� Date �,e� Print name ' d Phone* •eBci.�sae ed�r a.aet..rife h�this are.a be a�pieted M�dtr K rw..�chl eity or bw�: Permif�ee�e N �lxo�a�p�partoent ❑ehec![ffhmtdkk �� 's O�ee co.tu[peis..: ��, ��t'�t tM1�a scpc mw) ACORDn CERTIFICATE OF LIABILITY IN�UiZANCE � °08�;92009' PRODUCER S@f12I# 3356 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION KIRKILES 8 ASSOCIATES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COMAAERCIAL INSURANCE BROKERAGE LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 273 RIVER STREET NORWELL,MA 02061-2209 INSURERS AFFORDING COVERAGE NAIC# INSURED iNsuaER n: MASS RETAIL MERCHANTS ANTHONY'S CUMMAQUID INN, INC. INSURER B: RT,6A INSURER C: YARMOUTHPORT,MA OZF)7�J INSURER D: INSURER E:, •� COVERAGES THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABQV��O�t THE POUCY PERIOD MDICATED.NOTWI7HSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH.R�fiF'EGT TO WHICH THIS CERTIFI.CATE MAY BE ISSUED OR ' MAY PERTAIN,TME INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT T�',t A1_L'f'ri�TERMS, EXCtUS10NS AND CONDITIONS OF SUCH POUCIES,AGGRECaATE LIMITS SHmWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - - ��R N R� TYPE OF INSURANCE VOLICY NUMBER �LICY EFFECTIVE.uRUilT Y EX DRATION LIMRS GENERAL LIABIIITY ,� � - � � EACH OCCURRENCE s COMMERCUI.GENERAL LIABtLITV PDRME/MAG ETO RENTE� _ CLAIMS MADE �OCCUR MED EXP(M one rson S PERSONRL 8 ADV INJURV E GENERALAGGREGATE E GEN'L.AGGREGATE LIMIT APPLIES PER� PRODUCTS-COMP/OP AGG E POLICY PRO- �� AUTOMOBILE iIABIIITY � • COMBINED SINGIE UMIT s ANY AUTO (Ea seadeM) ALL OWNED AUTOS BODIIY tNJURY = SCHEDULED AUTOS (�� HIRED AUTOS ` BODILY INJURY NON-0WNED AUTOS � (PB��o�e�U . ..��'.,� �, � � PROPERTY DAMAGE � � ' k , (Per aecideM) _ �..�.,p^�"`..". . GARAGE LIABILITY � � ,�..� � ; AUTO ONLY-EA ACCIDENT t ANY AUTO ! ' �� EA ACC S 07HER THAN � � � AUTO ONLY: A� S E%CESS/UMBRELLA�IIABILITY EACH OCCURRENCE S OCCUR �CLAIMS MADE . AGGREGATE i i DEDUCTIBLE S RETfNT10N i s WORKERB COMPENSATION AND 014005031008109 1/1/2009 1/1/2010 X TO�Ry LIAGAINT� T� A EMVLOYERS'11A81LITY ` ANY PROPRIETORIPARTNER/EXECUTIVE El EACH ACCIDENT S SOO,OOO OFFICERIMEMBER EXCLUDED7 ' EL DiSEASE-EA EMPLOYEE S SOO,OOO If yes,descn'be under - SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT E SOO,OOO OTHER DESCRIPTION OF"OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENOORSEMENT/SPECIAI PROVI$�GNS�� . _...� �� : .�.. � . .�. :Ai�,;�. CERTIFICATE HOIDER CANCELWTION � SHOULD ANY OF THE ABOVE OESCRIBED P�ICIES BE CANCELLED BEFORE TME EXPIRATION TOWN OF YARMOUTH � . DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TOMAIL 30 DAYS WRITTEN BUI LDING I NSPECTOR NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL 99 BUCK ISLAND ROAD IMPOSE NOOBLIGATION OR LIAB(LITY OF ANY KIND UPON THE INSURER,RS AGENTS OR W.YARMOUTH, MA 02673 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �,-,.�,�'. -��c`'�.'yn u`' � ....,.... ACORD 25(2001108) O ACORD CORPORATION 1986 _ � - :";. ` -- D'ec 31 2009 2: 29PM Kirkiles a Rssociat�s CIH 781 -659-3386 p. l ACORD.� CERTIFICATE Of LIABILITY INSURANCE °z�3 00 ?RocuceR Serial# 3521 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION KIRKILES&ASSOCIATES ONiY AND CONFERS NO RIGHTS UPON THE CERTIFICATE WOL�ER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR COMMERCIAL INSURANCE BROKERAGE LLC ALTER THE COUERAGE AFFORDED BY THE POLICIES BELOW, 273 RIVER STREET NORWELL,MAb20s1=2209 INSURERS AFFORDING COVERAGE NAIC# wsuReo nvsuReR n: MASS RETAIL MERCHANTS ANTHONY'S CUMMAQUID INN, INC. iNSWRER B: RT.6A iNsuReR c: 1'ARMOUTHPORT, MA 02675 iivsurzER o: � � � � INSURER E: � . � � � . COVERAGES THE POUCIES OF INSURANCE LISTED BELOW HAVEBEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS CERTIFICATE MAY 6E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TME PaLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIORIS OF SUCH POIIGIES,AGGREGATEtIMITS SHOWN AAAY HqVE BEEN REDUCED BY PAID CLAIMS. INSR noo'�. � POLICY EFFECTIVE POUCY EXPIRATION � .� �� gR, . TYPE-0FINSURANCE � POLICYNUMBER D .�.1 � 1 Y D' � � 1Ml� LIMITS � � GENERAL LIABILITY EACH OCCURRENCE $ COM�NERCIAL G=NERAL LIA8ILITY . PREM�ES�Ea oecu�rence. $ . CLAIMS MADE �OCCUR MED EXP (Any onepersan) 8 � � � PERSONALB.�ADVINJURY � � � � GENERALAGGREGATE $. � � . � GEN'L AGGREGATE LIMIT APPLIES PER: PRDDUCTS-COMP.�OP A6G $ � PDLICY . .�E�. LOC.. . . � . . AUTOM1IOBILE LIABILITY . COMBINED SINCLE LIMIT � � ANY P,UTO � � (Ea attident) . � . � � .4LL OVJNED HUTOS � � BODILY INJURY � SCHEDULEO NUTOS � . (?Er pBfson) � � � � HIRED AUTOS BpDILY INJURY NON-OWNED AUTOS � (Per accidenq � 4 � � � . . . . � PROPERTI'DA�dAGE � . � . . (?sr accident) � �GARAGE UABILITY AUTO ONLY.-EA ACCIDENT�� 5 � � � � � AhY P.UTO . � � OTHER TFAN�� EA AC� � � . . � � AUTO�NLY: � AGG $ � . EXCESSIUIdBRELLA LIABILtTY � � EACH OCCURRENCE . . �� . OCCUR �CLAIMS MADE AGGREGAT� S � $ DECUCTIBIE $ RETEIV710N S � S WORKER'S COMPENSATION AND 0140050310081010 1/1f2010 111/2011 x, TOR�LlfJll S� . �ER� A EMPIOYERS'LIABILITY � ANY PROPRIETORIPARTNERlEXEGUTIVE EL EACH ACCIDENT £ SOO;OOO OFFIGEF2/1v1EME3ER IXCLUDED? EL DISEASE•E� EMPLOVEE $ SOD,DOO I`yes,des�nb:under � " . SPECIA.L�ROYIS ONS be'�.nw. EL DISEASE-POLIC�LIMIT $ SOO,OOO� OTH�R OESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTlSPECIAL PROVISIONS o� ` . � � � � D�� 3 �� 2��9 HEAL i h uc�� . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF 7HE ABOVE DESCRI3ED POLICIES BE CANCE_LED 6EFORE THE ExPIRATION� � �HTE THEREOF,THE iSSUING INSURER VYILL EN��EAVOR TO�f:NIL 30 �DAYS�bVP,ITTEN � TOW N OF YARMOUTH �OTICE TO THE CERTIFIC.ATE HOLDER NAMED-O?HE LEFf,5UT FAILURE TO DO�O SHALL HERLTH INSPECTOR PHILLIP RENAUD 99 B UCK ISLAN D ROAD IMPOSE NO OBUGAT�ON OR LIHBILITY OF ANY KIND UPO�'THE MSURER,ITS AGENTS CR W.YARMOUTH, MA 02673 RePREsen�TnTives. FAX.FJOH-7EO-347Z AUiHORIZEO ftEPRESENTATIVE � � � � . . � �.�Jt'ix.�lr�v_.�..F�c�i J ACORD 25{2001lOS) OO ACORD CORPORATION 1988