HomeMy WebLinkAboutApplication and WC1 � a�C�������'�' � '�=���
� TOWN OF YARMOUTS BOARD OF HEALTH � - :
� i
APPLICATION FOR LICENSE/PE 2� � t; �� ��' �UL � O C:;{;) �
�_` s � �
*Please complete form and attach all ne�essary d ts �G�e�c�� 1 (�Ost.r, u c�- + .
Failure to do so will result in the retum af ya pp�c ataon',pac .
NAME OF ESTABLISHMENT:
e�,1� I � TEL. # SaK-��� -�y 33
LOCATION ADDRESS: c�.�,..Q ,,� c.,r �. b t
MAILING ADDRESS: S �n�
OWNER NAME: � �� a I aX.� r -�/�m `v F - �
CORP
�RATIGIN NAME (IF ArrLIC LE): T (.� �o � �.,,
MANAGER'S NAME: �o � L.��� w� TEL. # ��Sf- �`�-(�,-C�S�
MAILING ADDRESS: S a-,N..� '
...��..�....._....�,..,,
POOL CERTIFICATIQNS: '
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 capy of the certificarion to this form.
1. 2,
Pool operators must list a minimwm of two employees currently certified in basic water safety,standard First Aid and
Community Cardiopulmonary Resuscitari�n(CPR). Please list these employees below and attach copies of employee
certificarions ta this form. The �iealth Department wi�i not use past years' records.;, You must provide new
copies aad 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 vu�ho is certified as a Food
Protecdon Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification ta this application. T6e Health Department will not use past years'records.
You must provide new copies and maintain a file at your estabGshment.
1. 1`n �C��- :L� �.� �,,� �,� 2.
PERSON IN CHARGE: '
Each food stablishment must have at least one Person In Charge (PIC) on site during hpurs of operation.
�� �� � L� r
1. � -�.-� �..� 2. �d�'`- L, �-t r h,. � �,
HEIIvILICH CERTIFICATIONS:
All food scrvice establishments with 2S seats or more must have at least one employe� trained in the Heimlich
Maneuver on the premises at all tumes. Please list yow employees mained in anri-choking procedures below and
attach copies of employee certificarions to tlus form. The Health Department will not use past years' records.
Yan muat provide new copies and maintain a file at your place of business.
1. �,
3• 4.
RESTAURANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING:
LIC�I�TSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENS�REQUIRED FEE PERMIT#
,_,_B&B $55 ^CABTN $55 ,_,_MOTEI,'', $55
�1NN $55 �CAMP $55 �SWIMM�NG POOI. �80ea.
�LOD(9E S55 (0�-O�( �TRAILER PARK $105 WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P�RMIT# LICENSE REQUIRED F�E PERMIT# LICENSE R�QUIRED FEE PERMtT#
I 0-100 SEATS $85 �lo�ceC'o _CONTINBNTAI. $35 NON-PROfiIT $30
>100 SEATS 5160 LCOMMON VIC. $60 �0– (Qe �WHOLESAL� S80
RETAII,SERVICE: —RESID.KITCH�N $80
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItBD FEE PERMIT# LICENSE It�QUIRED FEE PERMIT#
_<SO sq.tt. S50 >25,000 sq.R. $225 `VENDII�G-FOOD �25
.,_Q5,000 sq.R $80 _FROZEN DESSERT $40 TOBACCO �55
NAME CHANGE: sis AMOUNT DUE _ � 01-0 0,�p d ,
wwwww�LEASE TURN OVER AND C011�IPLETE OTHER SIDE OF FORM**"*"
r
: ADMINISTRATION
Under Chapter 152, Sectioi�25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or r�tvval
of any license or permit tb operate a business if a person or company does not have a Certificsta of Worker's :
Compensation Insurance. ', THE ATTACHED STATE WORKER'S COMPENSAITON INStTRANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT. OF INSURANCE ATTACHED �a (�� ��p�
OR
WOR'KER'S COMP. AFFIDAVIT SIGNED AND ATTACHE,1�
Town of Yarmouth taxes and liens must be paid prior o renewal or issuance of your permits. PLEASE CHLCK
APPROPRIATELY IF PASD:
YES NO i
i
MOTELS AND OTHER LODGING ESTABLISHML�'NTS
TRANSIENT OCCITPANCY: For purposes of the limitations of Motel or Hotel use,Transiem o�y shall be
limited to the temporary a�d short term occupancy,ordiwarily and customarily asaociated with motel and hotel use.
Transiern occupams must lyave and be able to demonstrate that they maurtain a principal place ofre�idGnce e�evv�e.
Transie�nt occupancy sha11': generally refer to cominuous occupancy of not more than thirty (34) days, and an
aggregate of not more than ninety(90) days within any six(6)month period. Use of a guest writ as a residence or
dwelling unit shall not be Considered t�ansient. Occupancy that is subject to the collection of Room Occupancy
Excise, as defined in M.G.L. a 64G or 830 CMR 64G, as amended, shall generally be considered Transiemt.
POOLS ;
�
POOL OPENING:All s�uwimming,wading and whirlpools which have been closai for the season must be' f
by the Health Department�p n'or to opening. Contact the Health Departmet�t to schedule the inspection tt�ree(�� i
pnor to opening.PLEASE NQTE:People are NOT allowe.cl to sit m the pool area until the pool has been uispected `
and opened. +
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4
POOL WATER TESTIl�tG: The water must be tested for pseudomonas,total coliform aad staadard plate couat
b a State certified lab, and submitted to the Health Department three (3) days prior to opeiring, and quarterly
�ereafter.
POOL CLOSIlVG: Every outdoor in ground swimming pool must be drained or coveted within seven('1)days of
closing. '
�� �
FOOD SERVICE �
CATERING POLICY: ;
Anyone who caters within the Town of Yarmouth must noti�y the Yarmouth Health Depart�n�c►t by r�th��re�quired �
Temporary Food 5ervice Application form 72 hours prior to the catered event. These fortns c.an be�>btained at the
Health Department. '
FROZEN DESSERTS: '
Frozen desserts must be t�sted on a monthly basis by a State certified lab. Test results must be sent to the Heatth
Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Pe,nmt uatit 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 ofHealt�.
OUTDOOR COOKII�TG,
Outdoor cooking,preparatYon,or display of any food product by a retail or food service establishmern is prohibited. ,
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBII.tTY TO REIVRN ,
TI�COMPLETED R�IV�WAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009. '
ALL RENOVATTONS T'4 ANY FOOD ESTABLISI��vlENT, MOTEL OR POOL (i.e., PA�lNT1NG, NEW
EQUIPMENT,ETC.),MIJST BE REPORTED TO AND PROVED BY TI�BOARD OF HEALTH PRIOR
TO COMMENCEMENT.II RENOVATIONS MAY REQ A SITE P .
DATE: �-- -�- °'� � SIGNATURE:
PRINT NAME&TITLE: ��• �- . ��� r -
09/25/09
�\ The Commonwealth of Massachusetts
Department of Industrial Accidents ;
�i�Nrl�l� ;
600 Washington Street, f"'Floor
� � Boston,Mass. 02I11 °
� Workers'Compeesatioe ieserance AfSdxvih Bailding/Plumbing/Electrical Coatractors E
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work site location ffull addressk
❑ I am a homeowner perfomring all work myself. Project Type: ❑New Constcuction QRemodel �
(��am a sole proprietor and have no one working in any capacity. Q Buiiding Addition C
❑ I am an eanployer providing wo�kkeis'compensation for my anpby�wodcing�this job. �
oomauv�me• �l_ /'f�Qo,/��l *o , _Lr. c ✓ ��"► "��17 n .�� �-�J LI ��c. I
�ddress: S �-' ��t r� � �
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❑ I am a sole prccypri�or,ge'eral costrachAc,or iameowaer(cirde one)and l�ve hired tbe co�tractars listed below who haven
ihe following w�kees'compensation polices:
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From:Faacserver80 To:Philip Renaud Date:7120/2010 Time,3:30:06 PM Page 1 cf 2
Eldredge & Lumpkin Insurance Agency,
I nc.
697 Main St.
Chatham MA 02633
Tel: (508) 945-0393
� � • a
To: Philip Renaud From: David D. Crawford
Fax #: 15087603472 Fax #: (508) 945-4048
Company: Town of Yarmouth - Health Tel #: (508) 945-0393
Subject: The Inn at Lewis Bay
Sent: 7/20I2010 at 3:25:18 PM Pages: 2 �including cover)
MESSAGE:
Good Afternoon, Philip:
Per my earlier conversafion with Bob Liberman, attached is a current certificate of insurance for fhe
Inn at Lewis Bay.
If you have any quesfions, please feel free to give me a calL '
Thank you.
Sincerely,
David Crawford
WinFax PRO Cover Page
Fr'om:Faxserver80 To:Philip Renaud Date:7l2012010 Time:3:30:06 PM Page 2 ot 2
ACORQ„ CERTIFICATE OF LIABILITY INSURANCE o��z�zo 0
� PRODUCER 508.945.0393 FA�X 508.945.4048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION� � ���''�,
El dredge & Lurt�ki n Ins. Agency ONLY AND CONFERS NO RIGHTS UPON TWE CERTIFICATE
HOLDER.THiS CERTIFICATE DOES NOT AMEND,EXTEND OR :
597 Mai n St reet ALTER THE COWERAGE AFFORDED BY THE POLIGIES BELOW.
Chatham, MA 02633
INSWRERS AFFORDING GOVERAGE N/YIC#
iNsureEo RTL Properties, Inc. ir�suRERA Lloyd's of London
DBA: DBA The Inn at Lewi s Bay in�suRER e
57 Mai ne Ave. iNsur�a c:
West Yarmouth� MA OZF)7� INSURER D:
ItJSIJRER E '
COVERAGES
THE POUCIES OF INSWRANGE LISTE�BELOW HAUE BEEN ISSUED TO THE INSWRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTAN�ING
ANY REQUIREMENT,TERM OR CONDITION Of ANY COWTRACT OR OTHER DOCUMEWT WITH RESPECT TO WHICH THIS CERTIFIGATE MAY BE ISSUED OR '
MAY PERTAIN,THE INSWRANCE AFFOR�ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND 60NDITIONS OF SUCH
POLI6IES.AGGREGATE UMIT5 SHOINfd MAY HAVE BEEN REDU6ED BY PAID CLAIMS.
INSR ���D' POUCYEFFECTIVE POLICYEXPIRATION !
� LTR NSR lYPE OF INSURANCE POLICY NWMBER ;DATE MMWD� � OATE fA1D�' � � LIMITS �
GENERAL L{ABILITY XSZO413H 06�3O�ZOZO 06�3O�ZO11 EHCH OCCU'r7RENCE � $ . I,000,00� ����:
X COMMERCIAL GENERAL LIABILiTY PREA�ISES(Ea occurrence � 5�,0�-
� CLAIMS MPDE a�CCUR � MED EXP IMY one person7 $ $ QQ
i_'
. A FERSONAi&ADV INJURY � $ I�OOO�OO��
GENERHL AGVREGATE. �. $ � Z,ODO,OO���� ��,.
GEN'L AI;GREriATE L IMIT HFPlIES FER: FRODUCTS-CGMF/OF Af G $ �,OOO,OO� �
POL�CY P�'� LCC '
JE CT
� AUTOMOBILE UABILITY
COt6�BINEDSWGLELIMIT $
.SNY AUTC. (Ea accideM)
.�LL C�WNEDAUTUS �
EODILY IN,JURY $
SCF�DULED A1.R05 (P�person) �
tiiRED HUTOS '
EODILY IN,1l,IRY $ j
NON-OVV�ED AUT�x tPer accidenq I
f
FROPER7Y DAMNGE � �
� (Per eCCideM) $ � ��..
GARAGE LIABIUTY RU i0 ONLY-EA ACGD=NT a
� FJVYAUTO OTHERTHAN 64ACC $ ..
AIJTO Ot�Y: AGG $
E%GESSIUMBREILALU181LITY � EACHQ�CURRENCE $ �:
�. OCCUR a CLAIMS MP�DE AGGREGATE $� ;
$
DEDUCTIBLE g
_
RETENTION ; y � j
WORKERS COMPENSATION - W '�
� AND EMPlOYERS'LIA8ILITY . Y�N ?ORY-;IMITS _R �',,
ANY'FROPRI`tOR�PARTPEFLEXECUTIVE ❑ E.L EACHAr_CIDENT $
�JFFICERrMEMBE�?E.XCWDED? ,
(Martdatory tn NH) � E.L DISE4SE-EA cMPLOYEE $
If yes,de5tnbe�.nder
SFECl41 PF4wSI0N5 b2�ew E.i.DISEASE-POLICY UMIT $ ,
OTHER . .�''...
4
DESCRIPTION OF OPERATIONS 1 IOCATIONS 1 VEHICLES f EXCLUSIONS AOOEU BY ENDORSEMENT I SPECIAL PROVISIONS �
Bed �4 Bed Breakfast Inn: The Inn at Lewis Bay, 57 Maine Ave. , West Yarmouth IhA 02673 �
GERTIFICATE HOLDER CANCELLATION
.
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE E%PIRATiON
� OATE THEREOF,THE ISSUING INSWRER Wlll ENDEAVOR TO MAIL lO �AYS WRITTEN
NOTICE TO THE CERTIFICATE WOI.DER NAMEO TO THE LEFT,8U7 FAILURE TO 00 SO SHALL �'�:
T own of Yarmouth IMPOSE ND OBIIGATION OR LIA81LIiY OF ANY KIND WPON THE INSURER,ITS AGENTS OR
Philip Renaud, Hed�LI'i II'iSp2CL01^ REPRESENTATIVES.
1146 Route 28 AUTHORIZE�REPRESENTATIVE
So th Yarmouth, MA 02664 Alan R. Lon , President
ACORD 25(2009/01) FAX: 50$.760.3472 OO 1988-2009 ACORD CORPORATION. All rights reserved.
The AGORD name and logo are registered marks of ACORD