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Home My WebLink AboutApplication and WC! � . . . � � � � TOWN OF YARMOUTH BOARD OF HEALTH - ' - -�� 4 � �� A P P L I C A T I O N F O R L I C E N S E/P F ��3 �-?�� M A Y 1 7 2 0 1 3 �--- ��33� �� * P lease comp le te form an d a ttac h a l l necess a r}�.�documen ts by D e� er 1 Q�PT Failure to do so will result in the return of your application pac ESTABLISHMENT NAME: ��r P�� '�rt�=(�- ��'`'-' TAX ID: �-�—��' LOCATION ADDRESS: �TZ 2�. zg $�J t�►a-�,u�..o v� TEL.#: 'S��r 3y� 4�� MAILING ADDRESS: �,✓�•�-r OWNER NAME: � l`ti i��'i(�- L Z- c CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: (�•a,e d,c c v��- �42t' 1�--1�-y l S,ad1�.<.r�TEL.#: sr��3yS�� MAILING ADDRESS: S✓a--�- 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.__ �r�� aLK..�'4. �� h�y`Zr,� 2. Pool uperators must list a minimurn 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 file at your place of business, b•� 1. .��l � 1�K.-� �� ov G�.� �.� �� z. 3. �"')c��4 �q.zz..� 4. '� �j. 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. 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 �le at your place of business. � L 2. 3. 4. �, RESTAURANT SEATING: TOTAL# I � i OFFICE USE ONLY ; LODGING: ' ; LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 _CABIN $55 1MOTEL $55 �S'�i3�S`F ; _INN $55 _CAMP $55 �SWIMMING POOL $80ea.��34�`I!. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea. � � FOOD SERVICE: i 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 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# j _<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 _ $ I 3 S� ' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** i b a 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 COMPENSATION INSURANCE ;I 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 j ;� ; 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 i Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. j 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 sub�:�t��d ta-the H€�lth_D�part�nent,_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. OiJTDOOR 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, 2012. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORT TO D APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEl�1ENT. RENOVATIONS AY UIRE A FtPLAN. 1 ' DATE: �. � � SIGNAT . PRINT NAME &TITLE: � � b ' T Rev. 10/09/12 1 • � - � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDMlYY) OS/22/2013 THIS CERTIFICATE iS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS r CERTtFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CbNSTITUTE 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, subject to the tertns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not co�fer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: PAIIL SCHI�EGEL INSURANCE ! SCHLEGEL INSIIftANCE BRORERS INC PHONE 508-771-8381 '4X 508-771-0663 � (AIC,No,Exq: (AIC,No). 34 MAIN STREET E�A�� SCHLEGELINSIIRANCE@VERIZON.NET ADDRESS: � �'.$T YARMOIITS MA 02673 PRODUCER CUSTOMER ID#: � INSURER�S)AFFORDING COVERAGE NAIC N INSURED � INSURER A sJ1RAVEI+ERS Bridge Over Corporation INSURER�B: 1 SIDDHARTH LANE INSURER C: - INSURER U: gO�TOO�C� I�, 02343 INSURER E: � � INSURER F: � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEIOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTR.4CT 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. R TYPE OF INSURANCE POLICY EFF POUCY LIMITS � �TR INSR NND POLiCY NUMBER (MMIDD/YYVY) (MMIDDIYYYY) � . GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIA�GENERAL LIABILITY PREMISES(Ea occurtence) a � CIAIMS•MADE ❑OCCUR MED EXP(Airy one person) 8 � PERSONAL&ADV INJURY S �. GENERALAGGREGATE S GEN'L AGGREGATE I.IMIT APPLIES PER: � PRODUCTS-COMP/OP AGG S POLICV jE a LOC $ - AUTOMOBILE LIABILI7Y COMBINED SINGLE LIMIT $ � _ (Ea accitleM) � ANY AUTO BODILY INJURY(Per pewon) $ � ALL OWNED AUTOS BODILY INJURY(Per accideM) $ ' SCHEDULED AUTOS ��. PROPERTY DAMAGE $ HIRED AUTOS (Per aceideM) � ` NON-OWNED AUTOS $ $ UMBRELLAIIAB OCCUR EACH OCCURRENCE $ � EXCESS LIAB CLAIMSMADE AGGREGATE $ . DEDUCTIBLE $ RETENTION $ . $ A WORKERSCOMPENSA710N WC-000978043 05/22/201305/22/2014 WCSTATU- OTH- AND EMPIOYERS'LIABWTY �,�N TORY LIMITS ER ' ANV PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ ZOO�OOO OFFICERIMEMBER EXCLUDED? ❑ N�A � (MandatoryinNH) E.L.DISEASE-EAEMPLOYEE $ ZOO�OOO �� If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ SOO�OOO ��. DE3CRIPTION OF OPERAT10N5I LOCATIONS/VEHICLES(Attach ACORD 707,Additional Remarks Schedule,i!more space is required) � ' CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOIITH ROUTE 28 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE YVILL BE DELIVERED IN F7EST YARMOUTH� MA 02673 ACCORDANCE WITH THE POLICY PROVISIONS. , � � AU7HORIZED REPRESENTATIVE HAND DELIVERED � �1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered ma f ACORD t . r r � CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DDlYWY) 05/22/2013 THIS CERTIFICATE IS ISSUED AS A AAATTER 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 BE�OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COMTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcate hoider is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to ' the tertns and conditions of the policy, certain policfes may require an endorsement. A statement on this ceRiflcate does not confer rights to the � certificate halder in lieu of such endorsement(s). PRODUCER � PAIIL SCSLEGEL IN$URANCE NAME: SCHLEGEL INSIIRANCE BROKLRS INC PHONE 508-771-8381 508-771-0663 �ac,No,exe�: lac,No�. 34 MAIN STI�EET E A SCHLEGELINSUItANCE@VERIZON.NET ADDRESS: WEST YARMOIITH � 02673 . cusroM�rsiur: � � INSURER(S)AFFORDING COVERAGE NAIC N . INSURED � INSURER A TRAVELERS Bridge Over Corporation INSURER B: 1 SIDDFiARTB LANL . INSURER C: � . INSURER D: Holbrook, MA 02343 INSURERE: "� - INSURER F: � COVERAGES CERTIFICATE NUM�ER: REVISION NUMBER: • i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 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 V�MICH THIS � M CERTIFICA7E MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESGRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 1 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN R • .. LTR TYPE OF INSURANCE �� p � pOLICY NUMBER �NWpM(YY) (MMIDD(YYYY) LIMITB GENERAL LIABILITY . . EACH OCCURRENCE 5 COMMERCIAL GENERAL LIABIIITY � ��T � PREMISES(Ea occurrenca) S CLAIM&MADE ❑OCCUR � � ME�EXP(My one person) 3 PERSONAL 8 ADV INJURY 5 � GENERALAGGREGATE S " GEN'L AGGREGATE LIMIT APPLIES PER: � � PRODUCTS-COMP/OP AGG S .. POLICY JECT �� g AUTOMOBILE LIABILITY . � COMBINED SINGLE lIM1T a ANY AUTO (Ea accldeM) BODILY INJURY(Per peraon) S �� AILOWNEDAUTOS . - - � - � BODILY INJURY(Per accidaM) $ SCHEWLED AUTOS PROPERTY DAMAGE a HIRED AUTOS (Per aeciAent) �II NON-OWNEDAUT0.S Y S ! I a � � UMBRELLALUIB ppCUR . EACHOCCURRENCE 5 � � ��B CLFUMS-MADE AGGREGATE 3 - DEDUCTIBLE � $ - RETENTION � S � - 5 : A watKerts coMv�n�sanoN . �PC-000978043 �5��201 05/22/2014 TORY LIMITS ER AND EMPLOYERS'LIABILITY . Y/N ANYPROPRIET6RIPARTNERIE%ECUTIVE � E.L.EACHACdDENT $ SOO�OOO OFFICER/MEMBER EXCLUDED7 ❑ N f A (Mandatory in NH) E.L.DISEASE•EA EMPIOVEE - S S OO�OOO . It yes,desuibe untler DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY IIMIT S 5OO�OOO � DESCRIPTION OF OPERA1T10NS I LOCA710N8/VENICLE8(AMach ACORD 701,Additfonal Remarlu Schedule,it more spm is requlrod) � . CERTIFICATE HOLDER CANCELLATION GAPE TRAVEI,ER BEACB �PaY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TMEREOF, NOTICE WILL BE DELIVERED IN ' Mp,y �g y� ACCORDANCE WITH THE POLICY PROVISION3. AUTHORIZED REPRESEN '.. HAND DELIV�RED , 88-2009 ACORD CORPORATION. Ali rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered m rks ACORD