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Home My WebLink AboutApplication and WC .�; �1=«�� i ,� * � � TOWN OF YARMOUTH BOARD OF HEALTH � W �� APPLICATION FOR LICENSE/PE�� -2��1 � �s�' ' - 4i�'•� � ��l�t� � :.� ,��'� �� ""� * Please complete form and attach all necessary docum � �; � c�� ''r 1 DEPT. Failure to do so will result in the return of ydur�ppIication pac . ESTABLISHMENT NAME: 'PA�n�a� I h�1S hC. � l�i' ' TAX ID• �' LOCATION ADDRES S: �S� S�"2�DY1 ,�h/.liYi N� , S OG�,�'AGI'►'I'►O[,�'� TEL.#:SOS�'Q�- �:.5$ MAILING ADDRESS: D $o)t l6YS.SO. �' �t DZ E-MAIL ADDRESS: %(i{�l�tG 1�' OWNER NAME: � �► • ' ►�' � D✓-L CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: i'�I (�G4'1e� Q TEL.#: �' � 3 MAILING ADDRESS: D . �� 6 D POOL CERTIFICATIONS: 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 copy of the certification to this form. l. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. 2. PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��c��,� J � �'a�sa� 2. � �Bu.-n-� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. 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. 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. 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 $110 INN $55 CAMP $55 SWIMMING POOL$110ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# < sq. 50 >25,000 sq.ft. $285 VENDING-FOOD $25 �<25,000 sq.ft. $150 � _FROZEN DESSERT $40 �TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ Z ro O. O� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 6 r : . _ ADMINISTRATION 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 ATTACHEDV� Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: �( YES `1/� NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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 thirly(30)da.ys,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 Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit 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. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. 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, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. � W�'� DATE: b 7iO SIGNATURE: PRINT NAME & TITLE: �� a��An� CJI l�- Rev. 10/O 1/15 . � ; � . - . The Corrctnonwealth o Massaclzusetts f : W Department oflndustrialAccidents _ � a 1 Congress Street, Suite 100 � Boston, MA 02I14-2017 5�•"`' www.mass.gov/dda ��'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers. TO BE FILED WITH THE PER712ITTING AUTHORITY. Appiicant Information Please Print Le�iblv N1ri1e (Business/Organization/Individual): �9TR�'ET s`Pr2.c?s �c c/% � ' � C lOyO I�f �Y� f ddress: �v d��k ��y,�- ity/State/Zip: v ,t ��,s yyj� 6z��a phone #: � g 6 S°� �S�y� Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with�employees(fuq and/or part-time).* 7. ❑New construction 2 I am a sole proprietor or partnership and have no empioyees working for me in any capacity, [Noworkers'comp. insurance required.] 8• � Remodeling 3.❑I am a homeowner doing all work myseif. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.❑I am a homeowner and wil]be hiring contractors to conduct afl work on m ro e j�,,i�� 10 ❑ Building addition Y P P m'� ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors tisted on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.= 1�•Q Roof repairs 6.Q We are a cotporation and its officers have exercised their right of exemption per MGL c. 14.�Othei C�nR� a�" c w.�� 152,§1(4),and we have no employees. [No workers'comp.insurance required.] '�X'}�'�1' `�st �l'��^J *Any applicant that checks box#1 must also filt out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing atl work and then hire outside contractors must submit a new affidavit indicating such. �Contractors that check this box must attached an additiona!sheet showing the name of the sub-contractors and state whether or not those entities have emptoyees. If the sub-contractors have empioyees,they must provide their workers'comp.policy number. I am an emplayer that is praviding workers'compensation insurance for nzy employees. Below is the policy and job site information. Insurance Company Name: �u,i3 Zn�•y� �yQ,,.�,j /Ueu, �f.,�,��,.,.�//�fi��s i�e(� �� /��-��.,�� G,o � Policy#or Self-ins.Lic.#: �`/a�,So ,�Z � y� Expiration Date: / ��/ � Job Site Address:�/S/ S7''�iTz"G.ti �}�.� y � !�, � 6��City/State/Zip: J. Y��,.c,Lt, , iur3 oZG�y Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the vioiator. A copy of this statement may be forwarded to the OfFice of Investigations of the DIA for insurance coverage verification. I do laereby certif under the pains and penalties of perjury thc�t t/te infornzation provided above is true and correct. � �Si nature: � � Date: Ki � �� Phone#: �Q Official use only. Do not write in t/ais area, to be completed by city or town official. City or Town: PermitlLicense# Issuing Authority (circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6.Other Contact Person• Phone#: Client#:304703 LIQUORNMOR ACORDrM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/08/2016 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:tf 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER �NAMEA 7 John Powers HUB International New England PHONE 508-945-7866 '4J� 866-323-4182 A/C,No,Ext: A/C,No: 265 Orleans Road E-MAIL North Chatham, MA 42650 ADDRESS: SOH 94S-O446 ; INSURER(S)APFORDING COVERAGE NAIC# i�NsuReRn;Mass Retail Merchants WC INSUR£D � Patriot Spirits Inc,Plymouth Liquors Inc i iNsuReR e: � i INSURER C: Wellfleet Wine 8�Spirits, Inc. �INSURER D: Bourne Liquors, Inc. , P.O. Box 1645 S. Dennis MA 02660 !�NSURER E: I INSURER F: COVERAGES CERTIFIGATE 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 PER100 INDICATED. NONlITHSTANDING 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 HERE�N IS SUBJECT TO ALL THE TERMS. EXC�USIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RE�UCED BY PAID CLAIMS. INSR ADOLISUBR POLICY EFF POUCY EXP l7R TYPE OF INSURANCE �INSR'NND� POLICY NUMBER MMlDD MM/DD/YYYY LIMRS ... . GENERAL LIABILITY � ; � . . ... . .... ... . i ��EACH OCCURRENCE $ �COMMERCIAL GENERAL LIABILITY I I I i i DAMAGE TO RENTED � PREMISES Ea occurrence $ – ClAIMS-MADE I I OCCUR � ( I MED EXP(Any one person) $ I I, •,' �PERSONAL&ADV INJURY $ i I I GENERALAGGREGATE 5 I i i GEN'L AGGREGATE lIM1T APPLIES PER: I { j �PRODUCTS•COMPJOP AGG $ (�� PRO- �� POLICY I ;JECT I �LOC ' ' � j `� AUTOMOBILE LIABILITY - I i COM8INED SINGLE LIMIT '�, i(Ea acciden[) 3 ANY AUTO ; ' � i BODILY INJURY(Per person) $ ALL OWNED SCHEDULED '� ' AUTOS �AUTOS ' �I � I BOOILY INJURY(Per accidenq $ NON-OiiVNED i i pROPERTY DA�IAGE g � HIRED AUTOS (qUTOS ' � Per accident t—� � i I $ UMBRELLA L�AB � I, OCCUR I � I EACH OCCURRENCE �$ EXCESS LIAB � CLAIMS-MADEI I ; �AGGREGATE $ DED � RETENTION S � I 3 A WORKERS COMPENSATION � ! WC STATU- .OTH- ANDEMPLOYERS'LIABILITY ! ; �14005032748 1/01/2016-01(01l2017! ANY PROPRIETOR/PARTNERlEXECUTIVE Y�N I ,I OFFICER/MEMBER EXCLUDED? a�N/A'��. I �E.l.EACH ACCIOENT SSOO,OOO (Mandatory in NH) 1 j E.L.DISEASE-EA EMPLOYEE SrJ�0,0�0 if yes,descnbe under � ' DESCRIPTION OF OPERATIONS below ! ! I E.L.OISEASE-POLICY LIMIT 3500,000 � I i � I 1 I i � I � � � DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACOR�10�,Additional Remarlcs Schedule,if more space is required) CERTIFICATE HOLDER CANCE�LATtON _ _ Town of Dennis SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN 465 Route 28 ACCORDANCE WffH THE POLICY PROVISIONS. Dennis Port, MA 02639 AUTHORIZED REPRESENTATIYE . O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(20t0/05) � pf� The ACORD name and logo are registered marks of ACORD #S1587815/M1587812 JP009