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Home My WebLink AboutApplication and WC _- . __ .. _ _ ..,....� r �; � ' \�" o r��=��'(��,=k. d�1�7 �S � TOWN OF YARMOUTH BOARD OF E�,��' �; �,� � APPLICATION FOR LICE E/PE I'�-�� 2 �` , ✓ _ ��Z�s�r * Please complete form and attach necess�ry oi b ber 3 2013. , Failure to do so will result�n the i�i f � t. ; t �:e �� .,;e�.� � ESTABLISHMENT NAME: '0'°� �' LOCATION ADDRESS: - l� y� O�G TEL.#: — -�f ,� MAILING ADDRESS✓Dd �,2�ss�:,��i/vd . �,4�✓-�_ .�r-��.�-, �:c�� 4i'7D:z E-MAIL ADDRESS: GSAtvtt�:;` � C��+-�6��-�i.�,c%�s.ns �. �om OWNER NAME: Cr,«Ei�-/r_�.,I �r.�..3 �� _ _— CORPORATION NAME (IF APPLIC BLE): MANAGER'S NAME�i�1.4 /�c�/"�f.�/�z TEL.#: _- MAILING ADDRESS: POOL CERTIFICATIONS: The pool superviser must be certified as��a�el��€rator,�s�•equired by State l��v. P��ase list t�e 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 safeiy, 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. I , FOOD PROTEC�ION MANAGERS - CERTIFICATIONS: -"` - J - _LL' All food service establishments are required to have at least one full-time employee who is certified as a Food Protection i Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach I copies of certification to this application. The Health Department will not use past years' records. You must I, provide new copies and maintain a �le 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 Sta.te 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 em�loyee trained in the Heimlich ; Maneuver on the premises at all times. Please list your employees trained in anti-cholcing procedures below and attach I 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. � i 3. 4. j I RESTAURANT SEATING: TOTAL# � 'r _ _ .: f OFFICE USE ONLY LODGING: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $55 INN $55 CAMP $55 SWIMMING POOL $80ea. 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 ' — — —RESID.KITCHEN $80 ! RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# i <50 sq.ft. $50 >25,000 sq.ft. $225 VENDING-FOOD $25 � �<25,000 sq.ft. $80 � C —FROZEN DESSERT $40 =TOBACCO $95 � � NAME CHANGE: $i s AMOUNT DUE _ $ 1.'I 5.C�O *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** _ _ _ .= y �� ! ADMINISTRATION ' Z . ' Under Chapter 1 S2, 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 MUSTBE � COMPLETED AND SIGNED, OR � ` CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 4 � Town of Yarmouth ta.xes and liens must be paid prior to renewal or issuance of your pertnits. PLEASE CHECK i 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 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 fo�tne season�nust b�-irispect�c�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. f POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a i 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.varmouth.ma.us under Health Department, Downloadable , Forms. I I 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: 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 RETIJRN 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: �' SIGNATURE: PR.INT NAME& TITLE: ' hard Fourni xe�. �o�osn3 Tax Manager J _ �� i � � ' f I • I - .. AC�• - - DATE(MM1DD/YYYY) � �— CERTIFICATE OF LIABILITY INSURANCE o3/2712013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO�DER. 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 BE7WEEN 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,subject to m the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate dces not confer rights to the ;.. certificate holder in lieu of such endorsement(s). � PRODUCER C�OMNEACT � � Aon Risk Services Northeast, Inc. P� (866) 283-7122 F'� (847) 953-5390 m vrovi dence RI offi ce �ac.na.exq: �,�,; ,a 100 westminster Street, lOth Floor e.�v� o Providence RI 02903-2393 USA ADDRESS: _ INSURER(S)AFFORWNG COVERAGE NAIC# INSURED � INSURER A rndemnity Insurance CO of�North America 43575 CUMBERLAND FARMS, INC. INSURERB: ACE M12f1Cd11 Insurance Company 22667 100 Crossing Boulevard Frami ngham hta 01702 USA INSURER C: 1 _ _ � _ .-.____. . . . _ . _i1V3URER D: . .. . _._ ... . � INSURER E: �� If�URER F: COVERAGES CERTIFICATE NUMBER:570049364753 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEQ TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING 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 HEREIN IS SUBJECT TO ALL THE TERMS, '; EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested �� LTR TYPE OP INSURANCE NSR NNO POLICY NUMBER MMIDDIYYYY MMIDDMlYY LIMITS i � GENERAL LIABILITY . � � . � EACH OCCURRENCE � i - COMMERCIAL GENERAL LIABILITY � � PREMISES Ea occurrence CLAIMS-MADE ❑OCCUR � MED EXP(My one person) � � � PERSONAL&ADV INJURY � M uy � � � GENERALAGGREGATE r � GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG m 0 �. POLICY PRa LOC O n AUTOMOBILE�IABILITY COMBINED SINGLE LIMIT .� . � � - Ea accident � ANY AUTO � � BODILY INJURY(Per penon) Z ALL OWNED SCHEDULED BODILY.INJURY(Peraccident) _ m AUTOS AUTOS . .. HIRED AUTOS NONAWNED � PROPERTY DAMAGE . V AUTOS Per accident w. � m UMBRELLA LJAB OCCUR EACH OCCURRENCE � C1 EXCESS LWB CLAIMS-MADE AGGREGATE DED RETENTION � � � � A WORKERSCOMPENSATIONAND WLRC43120876 � 04 Ol 2013 04 OY 2014 X WC STATU- OTH- B EMPLOYERS'L,IABILITY y�N SCFC43120888 04/Ol/2013 04/Ol/2014 TORV LIMITS ER � ANY PROPRIETOR I PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1�OOO�OOO OFFICERIMEMBER EXCIUDED? �N/A � . �� (Myeendatory in N►i) E.L.pISEASE-EA EMPLOYE� _ ...__..EI,.00O,OOO ,.- � � � DESCR�TION OF OPERATIONS below � E.L.DISEASE-POLICY LIMIT .ES,OOO,OOO_ � DESCWPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attaeh ACORD 101,Additional Remarks ScFrodule,H more apace is required) � � � � � The insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. � t � � ��..' CERTIFICATE HOLDER CANCELLATION � � �- � � � 8F10ULD ANY OF THE ABOVE DESCR�ED POLIqES BE CANCELLED HEFORE THE . EXPIRATION DATE THEREOF, NOTICE NALL BE DELNERED MJ ACCORDANCE WITH THE �- � POLICY PROVISIONS. . TOW� of varmouth AUTHORIZEDREPRESENTAi1VE �� Town clerk 1146 rtoute 28 South Yarmouth Ma, 02664 USA � `�;��P�� I/'�� J c,�/�s+t� . 01888-2010 ACORD CORPORATIQN.All rights reserved. ACORD 25(2070/05) The ACORD name and logo are registered marks of ACORD