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HomeMy WebLinkAboutApplication and WC� , � . _ . I � ► TOWN OF YARMOUTH BOARD OF HEALTH � u�S���J�� ' � �.. ; ; � � APPLICATION FOR LICENSE/$;� _, I 2 = �_ ,,,,,�e �,;. ��vF� �� ���? * Please complete form and attach all necess ' oc � s '� ber I S 2012. Failure to do so will result in the retu f your applicatio ac . LTH DEPT. ESTABLISHMENT NAME:�LA� (��,Ull1�, ���l�- C�-��1M,1�-S TAX ID• 4y LOCATIC)N ADDRESS:�6l Q�1��[. IS`�, P1d� W_�yGl,�'YYtD�+� > �l TEL.#: 5d'�-��R �b�13 � �, MAILiNU ADDRESS: ��- : � b OWNER NAME: �• l.V. 1�6Y191� �S4('.�Il 11Yl � � CORPORATION NAME (IF APPLICABLE): N � MANAGER'S NAME: TEL.#: � MAILING ADDRESS: ' POOL CERTIFICATIONS: The pool supervisar must be certified as a Pool Operator,as required by State law. Please list the designated , Pool Operator(s) and attach a co;ny of the certification to this farm. � �. �a v�e, �k,v�em� ; P�1�'�ec..�v� ` l�vt. . 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. .1�,�'►� �C�C-6Ci11� 2. 3. ►(Yti�P�S 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. 2. . _ __—_.---- ---- ---— �_ _ __ _ _ ._ - _-- _ ---- r� �Ji rii-L + _ _, _ --- - Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ' 1. 2. 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. T:�e Health Dep�rtmea�t:vil�a�at use p�st ye�rs' records. You musi�rc�vide new copies and maintain a file at your place of business. L 2. 3. 4. RESTAURANT SEATING: TOTAL# I OFFICE USE ONLY � LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# „ B&B $55 _CABIN $55 _MOTEL $55 - _ !�3-2:��. (p - - -- _INN $55 _CAMP $55 2. SWIMMING YOOL �23�ea.'�� % " 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 ', >100 SEATS $160 COMMON VIC. $60 _WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ; <50 sq.ft. $SG _ >25,000 sq.ft. $225 _ _ _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOI3,�CC0 $95 NAME CHANGE: $15 AMOUNT DUE = $ I(oO.�O I *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �' • _ _ _ �� � � .. �' �r" . . l� 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 MO�'ELS AND O'I`H�R�,€?DGI�TG ES'F���.:�SHI���TTS . . _._ . � ,_rt -� 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 sha11 generally refer to continuous occupancy of not more than thirly(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�e�'ine�i��'�vI.G�: C�F��-or�39 C��6-, as�c�;-sh�?� ��nerall.`.�hP rnnsi�ere�'ransient. __ 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 Department 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 obtained 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. OU1 SIDE CAFES: � �. ��__„__� Outside cafes i.e•,outdoor seatin�with�ai.terL�aitre�s��rir�}�3��13au��r�gp�€� . �G�€-�',�r. _ OUTD04R COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Per�nits 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.I, MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. _ DATE: SIGNATURE: PRINT NAME&TITLE: Rev. 10/09/12 ,�,..�•.� OP ID:SH � A�R0� CERTIFICATE 4F LIABILITY INSURANCE �A 10131)12vv� 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 CER7IFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 6e endorsed. If SUBROGATION IS WAIYEO, 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 Ileu of such endorsement s. PRO�UCER 781-247-7800 CONTACT Rodman Insurance Agency� IItC. PHONE FAx 145 Rosemary St., Bldg.A 781-444-0094 nrc No: Needham, MA 02494•3238 aooREss: ' Jeffrey Grosser PRODUCER gUCKI-2 TOMER �' INSURER(S)AFFOR�ING CDVERAGE NAIC# INSURED Buck island Village Condo �NsuReRn:Arbelia Protection Insurance CIO OffC2 INSURER B:St.PaUI F1�8 Sc M8fl118 481 BuCklsland Rd INSURERC: W Yarmouth,MA 02673 INSURER D: INSURER E: INS ER F• COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF �1SURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL�CY PERIOD INDICATED. NO'iWffHSTANDING ANY RE�UNtE?JIf.N.F,_TER�;dR EGYVDI'fJON°OF,LWrY CQNTR�,E'F��S O�THE� DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. ��R TYPE OF INSURANCE ADOL SUB � pOLICY NUMBER POLICY EFF POLICY EXP UMITS. T GENERALLIA8ILITY . EACHOCCURRENCE $ 'I,OOO,OO A X COMMERCIAL GENERAL LIABILITY 8500041883 � 01I01I12 011O1I'I3 pREMISES Eaoccurrence $ ���,�� CLAIMS-MADE a OCCUR MED EXP(Anyone person) $ 5,�� PERSONAL&ADV INJURY $ 'I,OOO,OO � � GENERALAGGREGATE $ Z�OOO�OO GEN'LAGGREGATELIMITAPPIIESPER: PRODUCTS-COMP/OPAG6 $ It1CIUCI@ POLICY PR� LOC $ AUTQMOBILE LIA81LITf .�: ......' .. . • .-. - ... .-.-_ .... _:_.. . -,�� �_. .. ,. ..... .. -., .. �pM81NED SINGIE LIMI? .. .. . . .. ., _. ..�_ ._ . .._..._ ..,.. . .., .... .�.:. _ . -.,.. ._- . � .. _.,.�, .. '- 7Eaacatlenq ANY AUTO BODILY INJURY(Per pereon) $ ALL OWNEDAUTOS BODILY INJURY(PeraccidentJ $ SCHEDULED AUTOS PROPERTY DAMAGE HIREDAUTOS (Per�accident� $ NON-OWNED AUTOS $ . $ x UMBRELLALIAB X OCCUR EACHOCCURRENCE $ 'IS,OOO�OO . EXCE33�IA8 CLAIMS-MADE AGGREGATE $ 'IS,OOO,OO g QK0650254721275 01/01/12 01/01/13 DEDUCTIBLE � � ��� � � � � . � � � � � � �� � � X RETENTION� �O OOO ' � $ 440RKER5 COPAPENSATION WC STATU- � OTH- AND EMPLOYERS'IIABILITY TORY�IMITS ER Y!N ANY PROPRIE�OR/PARTNER/EXECUTNE ❑ E.L EACH ACCIDENT $ _ OFFICERIMEMBER EXCIUDED9 N!A {Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ Ifyes,descnbeunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $ q Property Section 8500041883 01/01/12 01l01l13 RCISPEC 20,000,00 Follaws Condo Docs 117 UNITS � E10000 De DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 701 Additlonal Remarks Schedule,if more spaee Is required} 510,000 Wlnd Ded Each 81dg• Water Backup$50,000 w/$10000 Ded Fidelity 3475,000 w/$1000 Dec�; Directors&Officers 32,000,000 Boiler& Machinery incl in property CERTIFICATE HOLDER CANCELLATION YARMOUT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE NALL BE DELNERED IN Board of Health Dept ACCORDANCE WITH THE POLICY PROVISIONS. So Yarmouth,MA 02664 AUTHORIZED REPRESENTATI VE ��'�C" " — O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD � NOTEPAD BucK�-2 PAGE'2 �r,suReo�s N.a�ne Buck Island Village Condo OP ID:SH on� 10l31112 RC=Replacem ent Cost Coverage This form of insurance provides coverage on the basis of full replacement cost without deduction for depreciation on any loss sustained,subject to he terms of the co-insurance clause.This coverage applies to,both building and contents item s as specified on the face of the policy. No deduction is taken for depreciation in arriving at the proper amount of insurance needed to complywith the co-insurance clause.