The URL can be used to link to this page

Home My WebLink AboutApplication and WC . . . t�P�� ,_/ '��Ii��. � TOWN OF YARMOUTH BOARD OF HEALTH � � APPLICATION FOR LICENSEIPE I -7A �,�n L•'L�.� QJ LI;�J �" * Please complete form and attach all necessa�y „h� ;,D 'ember 13 2013. Failure to do so will result in the rett�n o��a�lica'�io T. ESTABLISHMENT NAME: � d �-G. T • �'� LOCATION ADDRESS: 6''II O�stin �.Sf pi �..sf�1�R�out,�� TEL.#: ..4'��'�'??'u'�dd.�'�f MAILING ADDRESS: SQ`n � E-MAIL ADDRESS: omQ��6� �7 9 �a�o� co�► OWNER NAME:_�'j.a,�IC_�- �Rrt .��s�C:R�c CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL.#: MAILING ADDRESS: 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. 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),having one certified employee on premises at alY 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. L 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 I provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ---_ _ 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. L 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 MOT'EL $55 INN $55 CAMP $55 SWIMMING POOL $80ea. LODGE $55 TRAILERPARK $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 — — —RESID.KITCHEN $80 RETAIL SERVICE: 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 _ $ S O.Ot'j **�**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � i ; •_ _ < < � , ; 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 1NSURANCE 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 OTHER LODGING ESTABLISHMENTS ' _ -- ___ _-__ - — - --- _ --- _ . __ __ ---- --- __._ _____- __ ---- --- - - 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 j not be consi�dered 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. . __ _ - --- --�- -- _ -- �--- - -' _ ��15�-�IZ"E------- - - - __-- 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. ' i OUTSIDE CAFES: i Outside cafes (i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOHING: 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 13,2013. 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. DATE: /2 Z /.3 SIGNATURE: � �� , ��``--7',� PR1NT NAME&TITLE:__ �GtR.I� �- �/I �(�r.fS��CiJQ� OGtI/1 C'/� ; Rev. 10/08/13 �� Dec. 3. 2013 11 ; 08AM Brigar Express Sfns 51$-438-0224 No. 999E P, 1 i � . ! ' DATE CERTIFICATE OF LIABI�.ITY INSURANCE 1�03/13 I Producer THIS CERTIFICATE lS ISSUED AS A MATT�R OF ! I{V�ORMATION ONLY ANb CONFERS NO RlGNTS UPON TME Assocla�lon Beneflfs Insurance Agency CERTIFlCATE iiOLDER. 7FiIS CEF2TIFICATE OOES NOT 289�aUardvals 5t,Suile� AM�ND,EXl"ENO OR ALTER THE COVERAGE AFFORDED BY Wltmington,MA O1B67 THE POLICIES BELOW. IMSURERS AFFORDING COVERAGE NAtC# Insured INSURER A MA Retell Merchanfs WC Group Inc. � Cape Godder Seaiood ivlarkef,lLC INSURER B: � 8y9 Maln St. j West Yarmoulb,MA 02673 IPISURER C: INSURER D; INSURER E: COVERAGES THE POLICIES 4F INSURANCE LISTEo BELOW 1�WVE BEEN 1SSU�b TO THE INSUREO NAMED ABOVE FOR TFiE POLICY PERI90 IN0ICAT�p,N47VNT�-LSTANOING ANY REqtl�REME�T TERM OR CONDITIQN OF ANY CON7RACT OR OTHER OOCUMENT Wiili RESP�GT TO WkiCH�T!!5 CERTI�IGATE AAAY BE 193UED OR MAY PERTAIN i}iE INSURANC�RFFORDEO aY7H@ POLICIES OESCRIBEDHEREIN IS SUBJECT TO AlL THE'fERMS.EXCI,USfQNs ANo CONDI7tOri5 oF SUCH POUCIE3. AGGREOA7E UMIT3 SHONT7 MAYNAVE BEEN R@DUCED 9Y PA1DGlA�MS. paucv Mn� EFFECTiVHDATE R]UCYIXFIRATfON � , P�t 1,1N WSAO TYPE OF INSURA1Vc� P011CY NUMBEH M QATE MM! WM�73� � �BNERAL LtABI!!TY EAG#i OCGURR� . C6MMERqALGENERALUAB1UTl' � WIREQAMAGE{MyoneR'e) 3 GLAIM3 MRp� Q O�IJR MED DW(hny o�gerson) $ PE�30NAL&ADV INJJRY y^ ' GB�lEf2/�L AGGftEGATE ^� . CiB,Pl AC3tlRE0ATE unaf7�1PPLIES PFR: FAOOUGI'8—COMplOP Ap0 PRO- �4LIGY J£CT WC AU�OMOBIIElIABIUTY OOMBlNEOSINGLELIMIT � qNy AllTp lEe aocNfenp ALL OWNBD AUTOS BODILY InraURY � �CF�DUIED AUf03 �pOf P°«^� HiH£0 AIJfQS BOOILY IIv.NF(Y � NON•OVNJED AUT03 (��a�0^�) PROPER7V GnMAL�E $ � (Parao�tlenQ � (�pRAO�A�AeIL1TY AUT40HLY—EAACCIDB1f a MfY AUl"O O1l1ER 7HMJ EA ACC $ � AUTO ONLV �G $ . E%CBSS LWBILITY EA4+qC[URFi�Jc� OGCUR � CWM&MaO� AGGREGATE $ � DEWGTIOLH $ REfINfIOtV S $ WORKFAS COMPEN3471DN AND WC ST.tTU. O7Ft PAIPLOYERSlIA&LITY X 70ftVUMlTS ER ANY PROPRIErER1PARTNERJD�ECUTIVE EL.EACH ACqCFNf AOFFlc�mt�e�FxcLuoear S 100,000 ��u�� NO 0140050324i4114 1I01/14 11�11/1b E�,OIr-,�A^,E—EA6MpLOYEE $ 100,000 ELO[SE0.SE—POWCYLIMIT $ 500,000 OTHeR �IPTIQN OF OPERATIONS�LOCATIONSf VF}lICLE3f IXCWSIONS ADOED 6Y EN04R�hteNY�5A�C9n�PROViS[ONS CERTIFICATE HOLDER woarount�N�,a�i�suaEa��-r�a: CANCEILAT{ON SHOUlDAIVY OF'i}iE A80VE O�SCRIB�D pOLIC�ES 9E CANCELLED BE�OR� Town of Yarmoulh l]1E EXPIRA710NORTE TrieREOF.7H��39UItd011�.9URERWILI ENDEAVOR TO ATTN:Heatlh pepa�iment MAI� 35 OAYS 1NRiT'f�N NOTIC�TO THE CER7IFlCATE NoIOER NAMEO 1146 Roule 29 Tq lTiE LEFT,BUT FAI�UftE TO 00 30 3HALL IMP03E NO 08LIOAiION OR Soulh Yar1T10U1h,MA 02664 LIABILITY�F ANY KIND UPoN 7ttE�nfSURER,I7S AG�NYS OR REPRESEN7ATIVES. AUTHORIZED REPRESENTATIV@ �} -'�--`^"'Y"� r . , 05/15/2014 9: 31 : 11 AM -0400 FAXCOM PAGE 2 OF 2 � � DATE(MMlDDlVYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE �,�� 5/15/2014 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 CERIIFICATE 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, subje�t to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does�ot confer rights to the certificate holder in lieu of such endorsement(s). � PRODUCER COMACT M1�CE A1aZZ01.3 NAME: Marketing Associates Insuraace Agency, Inc. PH°^'E . (617)964-5340 A,� No (617)965-1843 150 Wells Avenue E�`'�a�� mmazzola@telamonins.com ADDRESS: . INSURER(5j AFFORDING COVERAGE NAIC i Newton MA 02459 INSURERAAi[IGUARD I 2390 INSURED INSURERB NOrGUARD I151] � � 31470 IJG, Inc. , DHA: Cape Seafood Restaurant INSURERC: � BO Main StZfOt INSURERD: � i � MSURER E: ' Yarmouth MA 02673 - � INSURER F: ; COVERAGES CERTIFICATE NUMBER?�ster 14/15 THIS IS TO CERTIFY TNAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ' INDICATED. NOTNqTHSTANDING ANY REQUIREMENT, TEftM 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 7yPE CF INSURANCE ADDL SU R POUCY EFF POLICY ERP LIMITS LTR I POLICY NUMBER MIDDNYYY IdIDD/YYYY . GENERA�LIABILITY _qCH OCCUR�EnICE �. 1,000,000 acnn.ar_.E i o REnirE�� 50,000 .. X �.pMtdERCIAL GEVER�L LIAEI'�_IT� ?REfdISES Fa oc�urr2nc2 j� . A CL41M�-�.tCDE �OC:CUR JBP502172 /1/2019 /1/2015 y�ED EXP(Aryone per;on i � 5�� PERP,OM.4L S.�\�INJURY '� 1,OOO,OOO 3ENE�.cL AGGREG.c7E b 2,000,000 IiEML AlG�E6FTE�,IMT AFPLIES PER �ROD�C-S-C0�1F.�U�.4�31'+ � P�OOO�OOO X POLICY �R� LOC �' AUTOMOBILE LIABIUTY "OIdBIIJED SIIdGLE�IMIT �'Ea accdent i I AIVY'A:J70 BOD'�.LY'IP1JlJR`r iPzrparson) $ 'i � .4LL OV�NED �CHEDULED .4UTOS AU'OS 36DLY IMJU�Y;Per accidenq � 1 �ON-OV+AJED ?ROPERT"D.4AlHG= j � H'.�.RED.aJT05 A11-0S 'Peracdd2�! i � � X UMBREIIA LIAB X pCCIIR =ACH OCCUR�EPICE $ I.,OOO�OOO � — --__-___..._----------_—_ __.. I A EXCESS LIAB CLC��.fv1S-P�tADE AGG?EG.�TE '� 1,OOO�OOO o�e X �er�r:T�o�ia io,000 J(JM500317 /i/2oia /i/2ois � 1 B VNDRKERS COMPENSATION X 1h'C STATU- p1H- AND EMPLOVERS'LIABILITY T��RY UVIT� ER , FPI°PR^F'RIETOR.!PART�IER�E;iECUTIHE� NrA =.L EA�H ACCI�DENT 3� SOO OOO I OFFICER,T4EMBER E<CLJC!ED' ,7ydC515312 /1/2019 /1/2015 (Mandatory in NH) =L D'SE.iSE-E.S En4P'�_��YE � 500 000 II ves^descrrhe und?r DEJ��...RI�TION CF pPE�.STICPIS below =.L D'$EnSE-FOLIC�LIIdI' � �J�� A Liqtlor Liability JBP502172 /1/2019 /1/2015 �ominon C�use I imit $1,000�000 .qggregate L imil $2,0��,��0 DESCRIP710N OF OPERATIONS/LGLAT10N51 VEHIGLES �Attach ACORD 101,Additional Remarks Schedule,if more space is requircd) CERTIFICATE HOLDER CANCELLATION (508) 760-3472 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWIl Of YdZI[t011th ACCORDANCE WITN THE POUCY PROVISIONS. 1146 Route 28 S Yarmouth, MA OZ6G4 AUTHORIZEDREPRESENTATIVE � ,,� , Michael Susco/FPIT <..... L:�, , i;.�,_��-,-�^,.1._.x.. .�.., ACORD 25(2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved. INS0�5r�ni��,�m Tho AC(1Rn namP anri Innn arp rPnictnrorl markc nf AC(1R�1 05/151Z014 9; 31 : 11 AM -0400 FAXCOM PAGE 1 OF 2 ATTN: Town of Yarmouth FROM: Frankie Pitmon DATE: May 15 , 2014 SUBJECT: IJG, Inc. , IJBP502172 � JOB: 7180 ATTACH : "Form051520190928 . PDF" This Fax Originated From a Biscom ' Faxcom' . MEMO: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enclosed please find Certificate of Insurance as requested. Please let us know if you have any questions or need anything else. Thanks ! Frankie Frankie F. Pitmon Assistant Account Executive Telamon Insurance � Einancial Network Marketing Associates Insurance Agency, Inc. 150 Wells Avenue Newton, MA 02459 fpitmon�telamonins . com<mailto: fpitmon@telamonins . com> www. telamonins . com<http: //www. telamonins . com/>