HomeMy WebLinkAboutApplication and WC -_ .._,�, , �e�11ln�s-r�.� ,
� � � � TOWN OF YARMOUTH BOARD OF HEA �� , L��� ' o
= APPLICATION FOR LICENSE/PERM ��1 .,,o-
�e � � J 20.�� . , , g ��!�`� � �' 2��� �, ,�
�� * Please complete form and attach all necess � " ece ber IS Z010.
Failure to do so will result in the retu ��a `��i ication p eNEALTH DEPT.
�:3
ESTABLISHMENT NAME:�'��1S7n�ft� �R�C ��FoPs � �o0 3 ;
TAX ID:
LOCATION ADDRESS: �aQ RocJT� a�� tc7Es7' �i��2rKnvTH� NtA� oa1�73 TEL.#: 5b�•�75- 8�5�
MAILING ADDRESS:��c_v�ERrY AvE -�rr�v; ,Rt�K M��T., u,��D.N� n�S D7o�� , '
OWNER NAME: ��R��r�A�s �R�E �r�vPs, 1,,�,�. '
CORP4RATION NAME (IF APPLICABLE): s/-�rite �
MANAGER'S NAME: MA-�eK Gu�u/-�•vo TEL.#: �og-7?s- ���f i
MAILING ADDRESS:_�i�E �s �G,or/� '
POOL CERTIFICATIONS: �'�� '
The pool supervisor must be certi�ed as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a co�y of the certificatioii_to this fonn. __ . .
l. 2.
Pool operators must list a muiimum of two employees cui-�ently certified'ui basic water safety, standard Fu st Aid aud !
Community Cardiopulmonaiy Resuscitation(CPR). Please list tlYese employees below and attach copies of employee ;
certifications to this form. The Health Department will not use past 3-ears' records. You must provide ne�v
copies and maintain a file at your place of business.
1. 2.
3. 4.
i
�
FOOD PROTECTION MANAGERS - CERTIFICATIONS: y�A
All food service establishments are requued to have at least one fiill-time em�loyee who is certified as a Food
Protection Manager, as defined ui the State Saiutary Code for Food Seivice Establislunents, 105 CMR 590.000.
Please attach copies of cei�tification to this a�plication. The Health Department will not use past years'records.
You must provide new copies and maintain a file at your establishment. �
1. 2 �
PERSON IN CHARGE: _�._ _ �_�._,,._ -:__--- _ ._ -
I
--
--
��_�� �— ��_
-Eacii oo�stablis unent must have at Ieast o��
� �ne Person In Charge (PIC) on site duruig hours of operation.
1. 2.
HEIMLICH CERTIFICATIONS:
All food seivice establishments with 25 seats or more must l�ave at least one employee trained in the Hennlich
Maneuver on the premises at all times. Please list your employees trauied in anti-choking procedures below and
attach copies of employee certifications to this foinl. The Health Department will not use past years' records.
You must provide ne�v copies and maintain a �le at your place of business. ,
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL # D
OFFICE USE ONLY
LODGI�G:
LICENSE REQL�IRED FEE PERl�1II?= LICENSE REQUIRED FEE PER\�IT# LICENSE REQUIRED FEE PER'�III'# ',
_B&B S55 CABIN S55 MOTEL S5� I
—INN S5� CAMP _ Si5 S�ti?�-�+�ING PO�JL SEC:a.
_LODGE S55 �TRAILERPARK S10� ���Z-IIRLpOOL S80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERNIIT� LICENSE REQUIRED FEE PER�ZIT= LICENSE REQUIRED FEE PERiv1IT�
_0-100 SEArS S85 _CONTINENTAL S35 NON-PROFIT S30
_>100 SEATS S160 CO'_VIIvION VIC. S60 ��4'HOLESALE S80
RET.�IL SER�'ICE: —RESID.KITCHEN SSO
LICENSE REQUIRED FEE PERYIII'� LICENSE REQUIRED FEE PER�IIT# LICENSE REQL?IRED FEE PER'�IIT R
_<50 sq.ft. S50 _>25,000 sq.t�. S225 _VENDING-FOOD S25
�Q5,000 sq.ft. S30 ��1��{ _FROZEN DESSERT 540 _TOBACCO S>j
�A�ZE CHr�\GE: S15 AMOUNT DUE _ $ 80, p0
*****PLEASE TtiR\OVER A�D CO�IPLETE OTHER SIDE OF FOR�Z*****
1
�
� � .�, :
� ADMINI5TRATION
i
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
Ri�TELS AIV``� G�i"�E�t i.f��tTIi�ii��Ea�'��B1r.,I5�1"r��EItiTS
; 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 ofresidence elsewhere.
� Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an
aaggregate 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
pnor to operung.PLEASE NOTE:People are NOT allowed to srt m 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 ins�ected 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 obtauted at the
� Health.Department,or from the Town's website at www.varmouth.ma.us under Health Department,Downloadable
Forms.
FROZEN DES5ERTS:
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 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 RESPONSIBILII'I'TO RETLTRN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2010.
;
I ALL RENOVATIONS TO ANY FOOD ESTABLIS�IlVIENT, MOTEL OR POOL (i.e., PAINTING, NEW
� EQUIl'MENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIR SITE PLAN.
; DATE: GI/a?/!V SIGNATURE: �L�� d�
PRINT NAME&TITLE: ,��-F! f-�+��12.-'�/���Tp�° o� k p�� �G�-.
10�06%10
i } � �
. � /�
��\ The Commonwealth ofMassachusetts
Deparhnent of Industria!Accidents
�eSNb�
600 WasRingto»Street, 7`"'Floor
Boston,Mass. 02111
Workers'CompensAtioe inserance Affidavih Baildiog/Plambiag/Ekctrical Cowtractors
AnoHeaat i�m�tMn- Pkaae PRINT Ie�iM�r
„�: G,�Rl5�'/�RS j 2i � 3�6�P.� �L.� .
�da�s: to_�.� �t��i2�r� �✓E
__. —— --
_-�- -,
�ihr . �E'�.fJ state• �� zip �'7���_ ohone# �bPj'-lr��'('�S`� _
work site location(full address)-
❑ t am a homeowner performuig all work myself. Project Type: (]New Construc,�tion�Remodel
❑ I am a sole proprietor and have no one working Yn any capacity. ❑Bwlding Addition
[�I am an empioyer providing workecs'compensation for my empioyees working on this job.
_ _ _ _ > :
comwsv esme: �fl�lS�itijJ�� "�-���' $dtO�S 7S��OG�� _
addras- ^�✓�-� /'��t�Tb ,�2�
citr: ��5`i
�i�,2,aCCc�u�-�t ��,�- �o�- �75-Si�1
Insm�soe ca f�'RL'H Z�t15c1�'19-M�'-E �'oe�7 Pt4 N�! odkv# 1 l LtIJCi i��3�I'tL�3
, :.:., ;..
❑ I am a sole�xoprietor,general costractor,or homeo�vner(circ%nn�)and have hired the contractors listed below who have
the following workers'compensation polices:
comwav oame:
addresa•
��— nhoee N
ieamaaee co. __ odicv#
eomuaev aame:
addras-
c�' oro�e#
_ . _ _
- __ _----- ___
_ �as�rsurce ca _ _ nalicv#
Atl�e�k adi�l�tl+int��asra�
Faihu�e bs xemt oe�vvera�e n reqsired�'der Seelfo�ZSA st MGL 132 eaa ind t�tYe��dvioid pe�aWn�E'�fi�e�b f1.3A�0�aad/K �
ose Ycan'imprboaseet a�weY as dv/pesaNla h t3e[�o[a 3TOt WORK ORDER asd a Ane d 3180.0�a day a�imt ate, !oeden�d that a
C�py�[tih�falemeaf may be forwarded�s tAe OQice o[l�af t6e DIA far avense verieeatlw '
/do ber+eb ctrei w r Nie 1 d i
1' jy pen tles ofPerjWry t/Yat t/�e fafonwaHow provided aboae is trwe awd cornrt
Stgnatuc�e � Date �
I
Print namo (d�E� �-�Ifl�D�D�►Q.[�K nLC�I'ft'• Phone# 90 fs-!n�"-G�S�'�
eP8cia1 ux oNy do nM w�Nfe ie this arn te be rnupleted by cKy or�wo oBleial
city or tawu: ���
�Hnildh�a Department
QLkYe�inR Board
❑che�i[if imme�ale r+e�peme h reqaired �3deetmes's OfBee
QHeaNh De{nrfeeet
rnntact pennn• phoee N; �Q
(�e xyi mao�.
I
E
',
i
�
ACO� DATE�MMIDDlYYYY)
�,_,.; CERTIFICATE OF NABILITY INSURANCE PagB i af 2 o4�ia�2oio �
PRODUGER 877-945-7378 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
willis og New York, Znc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
26 century Blvd. ALTER THE COVERAGE AFFORDED BY 7HE P4UCIES BELOW.
P. O. Sox 305191 NAIC#
xashville, TN 37230-5191 INSURERSAFFORDINGCOVERAGE �
_.._ ___. _____ —__ ___ _ .__ _— _. _� _ - ---
---- - __.._.. , ...__ ____-- ...-__.�__^ . . __ . .___--- _
INSURED � � Chsiatmao Trea Shope, Inc. INSURERA Arch Ineusance_Com�nnY_ :� - 11150 002 '
__._ �.�.. ._-.__._ ,__ . -_.__�...._______.._ .� ., __
64 Leone Drive wsURER8: 3t Paul Fire and Marins Insurattce Com an 24767-001 �
Middleboro, MA 02396 � _.___ . ...�___ .. ..__.. . . .� _.___- ._. .---- -T .. _ ._ _..__.._...
. . . INSURERC: _-_ '----.___.. ,
' . � INSURER D: � -..,_----_„--.� ;
. . —.. -----�_...----`---._..--------.�..----.__.—_.__.____—._---
� � INSURER E: !
COVERAGES I
THE POLICIES OF INSURANCE LtSTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIQD INOICATED.NOTWITHSTANDWG
ANY REQUIREMENT,TERM OR GONUITION nP ANY CONTRACT OR OTMEft DOCUMEN7 WITM RESPECT TQ WHICN 7NIS CER7IFICATE MAY BE ISSUED OR
MAY PERTAfN,THE WSURANCE AFFORDED BY THE POLIGIE�DESCRIBED HEREIN 18 SUBJECT TO ALL TH[TERMS,EXCLUSIONS AND CONOITIONS OF SUCH
PO�ICIES.AGGREGATE LIMITS 5HOWN MAY HAVE BEEN REDUCE�BY PAID CLAIMS.
_ _ _____ ___ _ _ ..
._,_ ._ ____..__ �. ____. __. _ .--- --_ ___
-�--�- ��-�"-'-� ` PpUCYEFFECTiVETPOLICYEXPIRATIpNr
IN7 R N D' TYPE OF INSURANCE POLICV NUMBER A MM( �/YYYY T Ml� I VYY � LIMITS
A '� i� GENERALLIABIUTY 11GPP4934603 3�1�201� I�i 3�1��z�11 LACHOCCURRGNCE '8 ]. QO��QQQ_ _
i
� $ CGMMERCIALGENERALLIABILI(Y � ' IMEDEXN'TAnRoneFDson ��r$ �`-OOO OOO_ ;
�PR�MISES(Ea oocurena}
� � . .�� ...�CLAIMSMADE �_X_�OCCUR I � .. . � � . � � - - � (_y �_ �S . '.
_ _ ._..__ _.
I �-��� . � PERSQNALBADVINJURY ` 5_._Z�OOO�Q.O_Q._..
� ._.� ___ ..__ _.__�___ ..
I GENHRALAGGREGATE _ E ],.�QOiQOO__
� .__.1 __- -_._- ,-----..
-- -- —-
� GENLAGGREGATELIMITAPPUESPER: � PRODUCTS-COMPfOPAGG S_ �LQvO_Q�,._Q_Q�.
_._. ._-'-'
--'
i ..�...j POLICV PRO- LOC
j,, AUTOMOBIlEL1ABILITY AOS 11CA849344U3 ��1�2�1.0 3/1/2011 COMBINEDSINGLELIMIT S 1,�Q0�000 .
A X_i nNvnuTo MA 11CAB4934503 3/1/2010 3/1/2011 {eaa�+dent)
', i �'�. ALLOWNEDAUTOS BODILYINJURY $
� �-.-., (Perperson)
i � SCHFDULEDAUTQS __ ..__.________,. .._..----- -..__._ ,.._.____
i
. ..I I � I i ODIIY INJURV $ .
I
HIREQ AUTOS i
I Per aaclAent) .
� !� � NON-OWNEDAUT09 � � � .._._. .. _� .. __._ i
j � I i PROPERIVDAMAGE ;�� �
', _. � .... ._..._ ....._. .. � i
-.... � �(pAi acciden�l
� �
1.GARAGE LIABILITY I `OTHER THAN .�. . --.- a �--� .. _.... �
AUfO ONLY-t.A ACCIDLNT
I ... I �NVAUTO � I �.. �. � ..-- EAACC $ i
I i__..� I AUTOONLY: AGG� S '�-- -- � I
� f
$ EXCESSIUMBRELLALIABIUTY QKO9OOZO6� 3�I.�ZUZ.O 3�Z�ZO�.I. EACNOCCURRENCE _ . S__]sQ�_QOQ,�Q,QO._ �
� �
}[� OCCUR �_� CLAIMSMADE AG6RE6ATE _� ___ S ZQ,OOO�,._QO�_ �
I F -`- ;
� S {
---
�_._._�._ _._ _._.._�.
� ....� DEUUC716LE - __.__._ s .. ._..... .___.____ i
�.. . �--.._ .--.,.._ ,
� I RETENTION $ � a !
WORKERS COMPENSATION WC STAT - OTH- .
A AOS _11WCI4934103 3/1/2010 3/1/2011 � TORVSIMI�rs FR_ _._ _..______ �
- AND FDAPIOYBRB'UABIUTY
YIN
j� '� nNYVRUi�'RIETORlPAf2TNER/EXECUTIVEI -�I w= & �R 11WCI4934203 3��.�201� 3/1/2011 EL EACHACCIOENT . $ ,1�_�QQ �Q.�_,,. ,�
I OFFICEf2/MEMBER EXCI.UDE�'t
I�yes,describeunder ! 3�1�z010 �3�1�201'�' ELD�SFASE-EA_EMPLOYEE $ .],,_�.QDD�QQQ
A � ( Y )
Mandator ItiNN WA & OH 11WCX493430 i
I �;��.�:r.� �aqvisl�H� �iow� i � � '��.uisE nsF Noi.icrurniT��s �,,000,90 �
�I O7HER i ' � �
I I
DESCRIPTION OF OPERATIONS I 40CATIONS I VEHICLES I EXClU810N3 ADDED BY ENRORSEMEN7l SPECIAL PROVISION$
Evidence of Insurance
CERTIFIGATE HOLDER CANCELLATION
SHOUID ANY OF TNE ABOYE DESCRIBED POLICIES 8E CANCELLED BEFORE THE @7(PIRATION
DATE THEREOF,THE ISSUING INSUR@R WILI ENDEAVOR TO MAII _3� DAYS WRITTEN ��_
� � NOTICE TO THE,CER7IFICATE HOLDER NAME�TO TNE LEfT,BUT FAIWRE TO DO 30 SHALL �
Th0 COmmOIIW881th Of Ma968ChL3B6tt6 IMPOSE NO OBLIGATION OR LIABILITY Of ANV KIND UPON THE INSURER,ITS AGENTS OR ��.
Deptlitm0rit of Induetrial Accidents REPRESENTATIVES.
Off1Ce Of IRveetig8t10IIe . AUTNORIZEDREPRESENTATIVE '�
600 Washington Street ,
Hoston, MA 02111
ACORD25(2009t01) Co11:2966304 Tp1:1055996 Cert:14089699 �1988-2008ACORDCORPORATION.Allrightsreserved.
The ACORD name a�d logo ara registered marks of ACORD
. -
j Page 2 of 2
1
IMP4RTANT
i'
i
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
� This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend or aiter the coverage afforded by the policies listed thereon.
,
i
�
,
I
;
(
i
�
i
I
ACORD25(2009101) Co11:2986304 Tp1:1055996 Cert:14089699