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Home My WebLink AboutApplication and WC � .�` �� F( `, � �1V � ► TOWN OF YARMOUTH BOARD OF HEALTH rv� �,�k �� k„} ,�. �� APPLICATION FOR LICENSE/PERMIT -2012 '� � �,,r'�� a� � � . � � , ��.•f o� * Please complete form and attach all necessary documents by Decemb � IS ��11�� " Failure to do so will result in the return of your application pac t. `t��. SNo � � �s��r,�.�i's-. ';�)�:t�'E, ESTABLISHMENT NAME: �� P''<<<--Q 4�07�-`-C_/ TAX ID: �-(-�' �� LOCATION ADDRESS: "'�� 2 �� 2� TEL.#: ��i�,��q'L� �q Gq MAII.ING ADDRESS: ...�c��Tl� `�fk2 Mc�v'iw t`'( � . 0 2GG'�,r OWNER NAME: S�rt-�.5�+7 I<fa-1�1�,A G'�-�'--A CORPORATION NAME(IF APPLICABLE): � T��-1 � MANAGER'S NAME: � � (_1 1� �Qr'�� TEL.#: (� q � ��'� MAILING ADDRESS:_�°13 fz�T� 2��, .c�,��la `To��►•��D�t1� �..�,,Q,��,r-a_.r�_ � POOL CERTff ICATIONS: The pool sup :visor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatc :(s) and attach a copy of the certification to this form. 1. �r �---� Q �C Act�l s I?,��(2-A 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�le at your place of business. �. N� 1�f� �.ikt--FS'�+�t� 2. �t�-t P ��',��i� 3. C� 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All fa�d 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 wil�not use past years'records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: ' Each faod establishment must have at least one Person In Charge(PIC) on site during hours of operation. ' 1. 2. '', HEIM�ICH 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. i 3. 4. ; � RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERNIIT# _B&B $ss _caBnv �ss LMo�. $ss �12—OS� _INN $55 _CAMP $55 �SWIMMINGPOOL $80ea�� —G�,S _LODGE $55 _TRAII.ER PARK $105 _WHIRLPOOL $80ea. ' FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _0-100 SEATS $85 �CONTINENTAL $35 Z�l� _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. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25 _<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95 NAME CHANGE: $15 AMOUNT DUE _ �___1�O.�� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � -. i ADMINISTRATION . 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 COMI'ENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR , i 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 ' 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 OPEl�TING: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 i SEASONAL FOOD SERVICE OPE1vING: 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 waiterJwaitress 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 prolubited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2011. ' ALL RENOVATIONS TO ANY FOOD ESTABLISHIVIENT, 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: PRINT NAME&TITLE: Rev.10/25/11 .- -: � ' �` The Commonwealth of Massachusetts ' Departraent of Industria!AcciJents N��Ni�M�i 600 WashiRgton Street, 7`"'Floor Boston,Mass. 02111 Woricers'CompeOsation Iasorance Afftdavit: 1in• Pkase PRINT k�ibit name. ��{-�--�--�- 1��.�� --e. �,...n A �.-f 7 ��-L-- M C�� ,�... . addtess: --�-� �BV��----�-�__ city ��C�t��') �I�CK�`0 �71Y) state• ��Q zin• C��j nh�e# �.��$� r'Y'`i � / �� _. worlc site location ffiill addt+essl: ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and tiave no one working in any capacity. ❑ I am an employer providing workecs'compensation f�my employees wodcing on this job. comaauv woe: S"�l�r'� i—l�S (�('f7� 'L t'�`� - r �aa�• '7 g 3 �na �� -sT �e�: �o�'(h '7°h�-�� 'M��d2�c�i o��a- �S`a g7 G 9' �i "�^1 c g m.��. ��Y?v N �'�.�� a��..�.�., �� c�1 2�I .� �i I `� �, ; T ❑ I am a sole proprietor,geaeral costractor,or 6omeowner(cirdt owe)and have hired the contractas hsted below who have the following workers'compensation polices: - � COmDiYY�!' . . . f��qf' CIIY• . . . UYOO!�, . ,. Isl�ilt!CO. � �# - . . . COmDQY�fml: �� Yf/' . ChY: � � prp�!�' . . I�Qf�[!!Q - DOLiSY$ t A1�dr.+�i�1.r�..e rrrer.r� _ FaBQe o.xcme o.rva�e n req.6ee■.av seen..2SA.t MGL lst ea.kd a ue isp.�itl...tai�i.d pnaltla.t a S.e.p a s1,sM M a.a�.r �3^d�'�Pti��eet n wd�s dH peiaNb h tbe t�r�et a 3TOt WOItK ORDER ud a A�e ef f1A�.W a dar apJmt se. !a�dentud tiat a eepy�t tYb�ta4se�t m�y be forwarded 1s the Omee�t�et tie DIA hr e�reraie v�eriAeaUw /do ber+tby cerffjy weder NYe poiws swr pe�e�Niei ojperjary tUr�t NYe iafonwdloe prodre!eboat tr bare awd oonrct S�gnature ��D^^—� "'�� pan �''�2�j � � 2 Print aame � � L I � 1�1"'��'�A�'/>!(�� Phone# \�� v�'i �� / eBclal ax a�ly do not wrke b thb area to 6e cosPieted 6Y citY or Nwn ogichl city or tewn: P��K QBaidlea Depar�eet ❑eheet if ImmedVle reapeme b reqaired �� 3datse�s Of�ce i �NeaMr D[�arB�eRt � coatact persoo: ph�#� � cti,�a s.�.mm� i f I ( T '4�� CERTIFICATE OF LIABILITY INSURANCE °"'�`�M'°°""�", 5/15/2012 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF 1NFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, 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 i REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statemerrt on this certificate does not confer rights to the certificate holder in lieu of such endorsemerrt(s). PRODUCER TACT� tOA Insurance NAME: Yn BOyI1tOA Insurance Agency PHONE . (7g1)449-6786 F� .(781>449-6269 72 River Park. Street -MA�� INSURE S AFFORDING COVERAGE NAIC# Needham MA 02494 iNsuReRa:Versnont Mutual INSURED INSURER 8:NOrfO�.�C � Dedham Grou Sarkar Hospitality LLC, DBA: Red Mill Motel INSURERC: 793 Main S�Seet IIiSURER D: R011t@ 2 S INSURER E: South Yarmouth MA 02664-5204 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1251504191 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOIWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH 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.IIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POUCY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YWY MMIDD/WYY LIMITS A GENERAL LIABILI7Y P11032560 EACH OCCURRENCE $ 1�OOO�OOO X COMMERCIAL GENERAL LIABILITY DA , �R€�- PREMISES Eaoccurrenc S 50,000 CLAIMS�AADE a OCCUR MED EXP(Arry orre person) $ 5�OOO PERSONAL&ADV INJURY $ 1�OOO�OOO GENERAL AGGREGATE $ Z,OOO�OOO GEN'L AGGREGATE L1MR APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- L� $ AUTOMOBIIE LJABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per petson) $ ALL OWNED SCHEDULED BODILY INJLIRY Per accident) $ AUTOS AUTOS � NON-ONMED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ S UMBRELL/4 LIAB OCCUR EACH OCCURRENCE $ IXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ $ YVORKERS COMPENSA710N � WC STATU- OTH- AND EMPLOYER5 IIABILITY Y/N ' ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ ZOO OOO OFFICER/MEMBER EXCLUDED? ❑ N/A ' (Mandatory in NH) 128033A /15/2012 /15/2013 E.L.DiSEASE-EA EMPIOYE $ 100 000 ' If yes,descnbe urxier DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $ 500 OOO DESCRIPTION OF OPERATIONS/LOCA710NS/VEHICLES(Attach ACORD 701,Ad�Nonal Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TO WhOm It May Concern ACCORDANCE WITH THE POUCY PROYISIONS. AUTHORIZED REPRESENTATNE ' Dinesh Tanna/KTAN ��-=�L� �------«._ I ACORD 25(2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved. � INS025��mnn5i m Tho Af`ARII n�mn�nrl Innn�rn ronie+nrnri m��4e nf Af`ARi1 �