HomeMy WebLinkAboutApplication and WC � R�c�iv�D
TOWN OF YARMQUTH BOARD OF I�.4LTH
APPLICATION FOR LICEN�FJPERMIT-2Q17 (��,T �! � �(�f 6
*Plea�comptete form and attach all necessary d�uments hy m er I6 2016.
Failure ta do so will result in the retiun of your applic,a�on pac cet. HEALTH DEPT.
ESTABLISHMENT NAME: /.t� -�
LOCATiQN ADDRESS:� N TEL.#: D — �'l'7 —833,3'
MAILING ADDRESS: $l RM l' `" �--�' � "'��"_
E-MAIL ADDRESS: � D L •L'O � C����
QWNER NAME� ! �Q �v t�= � =�,
CORPORATION NAME(I�APPLTC ): � � � �`' .. :� `' `�� "' �'
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MANAGER'S NAME: � TEL.#: � O.� e
�u..nv�annxEss: /� • , .�4,t��,3
PQOL CERTIFICATiONS:
TLe pool snpervisor mast be cert3fiai as a Pool Qperator,as neqnired by StAte law.Please list the designated
Pool aperator(s)and aitach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum af two employees cuirently c.ertified in standard First Aid and Cammunity
Cardiopulmonary Resuscitation(GPR},having one certified enploy�on premises at all times. Please list the
employees below and sttach copies of their cerhfications to tt►xs form.The Healt�Deparhnent wiII aot a�e past
yeara'records. You must provide aew copiea gnd�aiataia�file at your place of basiness.
1. 2.
3. 4.
FOOD PRO'£ECTIQN MANAGERS-GERTIFICATTONS:
All food seivice estabtishments are required to have at least one fuil-time employee who is ccrtified as a Foad ,
Protection Manager,as defi�d in the State Sanitary Code fbr F�d Service Establishments, 105 CMR 590.000. '
Pl�se attach copies of certification to this application The Health l?epartiment wiU not nse paat years'r�ards. ';
Yoa mnst provide aew copies and maintais a file at yoar establishment. '
1. �U� �i J4/1�/�lJv 2. ��/ C>'/f�'�/ii/r� !'
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PERSt3N IN CHAI�G�:
Each foad establishmen#m�st have at least one Person In Charge(PIC)on site during hours of operation.
.
�.T,y �.�it,D�,�va 2. ,�D,Q ��D/.v�
ALI,ERGEN CERTTFICATTONS:
All food service establishments are require@ w have at least one fiill-time employee who has Allergen certificarian,
as defi�d in the State Sanitary Gode for Food Service Esteblishments,105 CMR 59Q.0�09(G)(3)(a). Please attach
copies of certific�tion to this appticatioa The Health Department will aot nse past years'records. Yoa mast i
provide aew copiea sad msind�a file at yonr establiahmea� � i
1. ,��� �//¢/L�/N� 2. �� CT/��/V�
HEIMLICH CERTIFICATIONS:
All food service estabGshments with 25 seats or more must have at iast one empioyee usined 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. T�e Health Department w�il!not ase psst yeara'necords.
Yon mast provide ae�r copies snd maintaia a file at yonr place o#basinesst
.�- r � ,��1
1._,l�/�l �.,r1�2Qf'�(/ 2. L��l/ ��'W/�.�->�
3. 4.
RESTAURAN'f SEATING: TOTAL# �
i.oncnvG:
OFFICE USE ONLY
LIC&NSE REQUIREQ FEE PF.Rh�II7'# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMt'i'#
�B SSS CABIN S55 MOTEL SIIO
�NN1 S33 CAi�iP SSS =SWIMMING POOL il IOea.
_LODG$ SSS TIWLERPARK S10S _WHIRLPOOL SliOea
FOOD SSRVICE: i
LICENSE REOUIRED FEE PERMIT A LICENSE REQUIRED FEE PERMIT tl LICENSE REQUIRED FEE P£RMIT Y
tl-l00 SE?ir•s S125 CONfIi1ENTAL S33 NON-PROFIT S30
=>10l?SEATS 5300 � �,COMMON VlC. S60 ��j �VI30LESALE S80
—RES[D.KITCHEN S�
RETAIL SERVICE:
L[CENSE REQUIRED FEE PERMff� LICENSE REQUIRED FEE PERMiT# LICENSE REQI1tRED FEE PERMiT# ;
'�30 !k S30 >25,000 ft. 5285 VENDING-FOOD S25
=45,�u}.R. SISO �`[tOZEN�ESSERT S40 =TOBACCO 5110
I�tAME CHANGE: S15 AMOIJ1�lT DUE = S3�QQ �
•"••°PLEAfiE TURN OYER AND COMPLETE OTHER SIDE OF FORM*�'•*•
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' ADMIr1ISTRAT'ION
Under Chaptet 152,Section 25C,Subsecrion 6,the Town of Ysrmouth is now required to hold issusnce 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 ATTACFIED STATE WORKER'S COMPENSATION INSLTRANCE
AFFIDAVIT MUST BE CQMPLETED AND SIGNED,UR
CERT.OF INSURAIVCE ATTACHED ✓
OR
WORKER'S COMP.AFFEDAVTI"SIGNED AND ATTACHED
Town of Yarmouth taxes and tiens must be paid prior to renewal or issuartce of your permits. PLEASE CHECK
APPROPItIATELY IF PAID:
1'ES�C NO
MOTELS AND OTHER LaDGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel or Hoeei use,Transient occupancy shall be
limited to the temparary and short term occupancy,ordinazily and customarity associated with motel and hotel use.
Transient occupaats must have and be able to demonstrate that they maintain a princi�l p(ace of residence
elsewhere.Transient occupancy shall generally re€er to contin�us occupattcy of not more than thirty(30)days,atld
an aggregate of not more than ninety(90)days witfiin any s'v�(b}month period. Use of a guest unit as a residence ar
dwelling unit shatl not be cc>nsidered transient. (kcupaney that is subject to the collection of Roorn Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,sha(i genera(ly be considered Transient.
POOI.S
POOL OPENING:AYl swimming,wadiag and whirlpools wtrich have been closed for the season must be inspected �
by the Hesith Department prior to opemng. Contact the Health Department to acheduk the uu�etion thr�(3)
dayt�s pt����o�mg.PLEASE NOTE:People are NOT allowed to sit in the poot area until the pool has been
POOL WATER TFSTING: The water must be tested for pseudamonas,total coliforra and standard plate count
by a State certified lab,and submitted to the Health Department thr�(3)days prior to opening,and quarterty
thec�eafter.
POOL CLOSING:Every autdoor in ground scvimming poo!must be drained or covered wiihin seven(7j days of
clos�ng.
FOOI}SERVIGE
SEASONAL FOOD SERYICE QPENING:
All food service establishments must be inspec;ted by the�-leslth Department prior tu ogening. Please contact the
Health Department to schedule the inspection three(3}days prioe to opemng.
CATERING POLICY:
Anyone who eaters within the Town of Yazmouth must notify the Yarmouth Health Department by filing the
req��ie�rary�F� Service Application form 72 hours prior to the catered eveat. These forms can be
Eal partment,or from the Town's website at www.yazmouth.ma.as under Health Dep�rtment,
Downlaadable Forn�s.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thercafter,with sample results
submitted to the Health Department Failure to do so wil!resuit in the suspension or revocativn of your Frazen
Dessert Permit until the above tercvs have been me�
OUTSIDE CAF�S:
Outside cafes(ie.,outdoor s�ting with waiter/waitress service),must have prior approvat from the Board of H�Ith.
OUTDOOR C�KING:
OuWoor cooking,preparation,or display of arry food pmduct by a retail or food service establishment is prohfibited.
NOTTCE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S}ANp REQUIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVA7TONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIIVTING, NEW
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TI-IE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIQNS MAY REQUIRE A STfE PL . '
DATE:j//^p?o�� I�p SIGNATURE: -
PRINT NAME&TITLE: �,DGl,'/��0�/7". C�fr4/�Z�Diti� V �
t�.�atu�6 �R�/�e�t/�
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i � The Com�reunwealt�r of MassarhuseKs
' Deparhnent ojlndustrial Accidents
Offic�of in►�estigatiores
1 Congress Stree�,Suite 1�
Bostore,MA 42114-2017
www:�rtss gov/dia
Workecs' Compensation Iesuraace Affidavit: General Businesses
AnDticant InformatioH Please Print Legiblv
Business/Organization Name: �.i
Address: G� ? � /�'9/�-i nJ , �'�' ��► �
M� oa�73
CityfState/Zip:�,IJG.l Fhone#: ,�D �— /'�'�'�=0�_�„3
Ar�e you sa e�gloyer�Check t�e apprapriate boz: 8nsiness Type(reqnired):
1.L'�J i am a emplayer with�_employees(full and/ 5. ❑Retail
or part-time).* b. [�'�estaurantlBar/Eaiing Establishment
2.❑ I am a sole pro�ietor or parqYership and have no 7. ❑Office and/or Saies{incl.resI estate,suto,etc.)
employees working for me in any capacity.
[Na workeis'comp.insurance required] S. ❑Non-profit
3.❑ We are a corparation and its officers have�xercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4�,anci we have �p.0�ufacturing
no empioyees.[No warkers'comp.insursnce re,qniredJ*
4.❑ We are a non-profit organization,staffed by volunteers, I 1.Q Health Care
with na employees. [No warkers'comp.insurance req.] 1Z.Q Qther
'�Y aPPGc�aot thaat chacJcs box#i must a3so fifl art the secti�below showing th�ir w�lar�s'oompa�ion Policy infocmation.
ssIf the aaparatt offioers}sava exempud th�selves,but the eozpa�ian has otha emPbY�s,a u�s'compa�s�ia�Poli�3'is t+equited amd snch an
o�ian should checic bo�c#1.
I am an emplayer tJf�at is prov�Cling work�rs'caQx�pe�sae�n�ix,atra�tce jor nty e�etptoye� Below is tlie palfiy�nfosn�itnn.
Insurance Company Name: .� �r P� /�i � ,�'s�.('u C� � C -�iV G
Insw�er's Address: � B . l�d � ,I�iQ�`�
CitylState/Zip: ��Gf N ��/�' � �/9• �� / C1 �
Policy#or Self-ins.Lic.#�� �.cJ �' � �� ��,__Expiration Date:
Attac�a oupy of the workera'oompenaadoa poticy deciaration psge(showing the policy nnmber and ezpirstian dat�),
Failure to secure coverage as required under Sextion ZSA of MGL c. 152 can te�to the itnposition of criminal penal6es of a
fine up ta�t,500.00 ancUar one-year im�isanment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to�250.0(3 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cuYify,under tlke fpe�jury et e orneuA�ort provided above is ttue aird correex
:����� /-6
#- � 7 �- ,3
Off iclel use oxly l�o Rot wr�te in tlhis area,to be conrpleted by c�ty or town officiaL
City or Town: Permit/Ucense# :
Issning Aathority(circk one): ''
1.Board of Healt6 2.Bnildiag Dep�rtmeet 3.City/Town Clerk 4.Licegsiag Board 5.Sel�en's Office
6.Other '
Coatsct Person• p��#• ;
www.mags.�v/dia
i
i�"'1 GIARD-1 OP iD:DL
'`�i Q��s CERTIFICATE C)F LIABILITY INSURANCE °��`""u°°""'"'
09/12/2016
THIS CERTIFICATE IS ISSUEp AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIYEIY OR NEGATIVEIY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiflcate holder ia an ADDITIONAL INSURED,the pol(cy(les)must be endorsed. If SUBROGATION IS WANED,subJect to
tl►e terms and conditions of the policy,certain policies may require an endorsement. A statemerrt on thfs certiflcate d�s rtot confer rights to the
certificate hoider in lieu of such endorsement s.
PRQDUCER N,�� Gordon G.Asack
DGP-Miles Insurance Agency,lnc . PHoaE Fnx
3 School Street P.O.Box 1018 .508-824-8961 aE �,�,;508-880-2734
Taunton,MA o2780-0957 „'""^��;gasac d milesins.com
Gordon G.Asack
INSURE S AFFORDINGCOVERAGE NAIC!
x�s�r�A:Guard Insurance Caroup
iNsuaeo Giardino's Tastee Tower Inc w���,;Harleysville Insurance Ca
Eddle Giardino
242 Main St. �����
West Yarmouth,MA 02673 �sur+Ea n:
MISURER E:
WSURER F:
COVERAGES CERTIFICATE NUMBER: REYISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PQLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TNIS
CERTIFICATE MAY BE ISSUED QR MAY PERTAIN, T'HE 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.
LT�R TYPE�INSURANCE POUCY NUMBER Y F POLICY LIMIT8
l3ENERAL LIA91LtTY EACH QCCURRENCE $ 1,000,00
B X COMMERCIAL GENERAL LIABILITY GL37495W 08J01/2016 08/01/2017 pREMISES Ea ocdurence E 1 QO���
CWMS-MADE �OCCUR MED EXP(My one peraon) $ S,OO
PERSONAL&ADV INJURY $ 'I,OOO,OO
GENERALAGGREGATE E Z�OOO�
GEN'L AGGREGATE lIM1T APPLIES PER: PRODUCTS-COMP/OP AGG $ Y,OOO�OO
POIICY PRO �� �
AUTOMOBILE LIABiLITY C BiNED SINGLE LIMIT
Ea 8Cdd9M
ANY AUTO BODILY INJURY{Per person) $
ALL OWNED SCHEDULED BOOILY INJURY(Per acdd�t) $
AUTOS AUTOS
HIRED AUTOS �ON-0WNED OPERTY D GE s
AUTOS PER ACCIDE
$
X UMBRELLA LIAB X occuR Eac+�occuw�Nce g 1,000,00
B IXCESS UAB CLAIM&MADE CMB34586W 08/01/2016 08/01/2077 qr,C,�r,qTE S 1,000,00
DED X RETENTION �O OOO S
M1pRKER3 CONpEq8J1T10N WC STATU- OTH-
AND EMPLOYERS'LIABI�ITY
A ANY PROPRIETORIPARTNERfEXECUTNE Y f N GIWCBSOSS7 O�'I/ZO'IB Q�/Q'FI�'Oil E.L.EACH ACCIDENT a 1 OO,OO
OFFICEWMERABER EXCLUDED? � N/A
(Mandatory In NH) E.I..OISEASE-EA EMPLOYE a 100���
If desrliba under
yes sr
DESCRiPTION OF OPERATIONS betow E.L OISEASE-POLICY UMIT a �JOO,� ;
B Harelysville Insur GL31495W 08101f2016 08/01Y2017 UQUOR 7,000,00 '
Aggregate 2,000,00
DESCRIPTION OF OPERATIONS i LOCATIONS/VEHICLES(Atlach ACORD 101.AddlGonN Ranarks 3chedule,�moro spsae Is rcquiret�
Proof of insurance subjeot to actual policy terms, conditions, limits,
defiaitions, and excluaions.
CERTIFICATE HOLDER CANCELI.ATION
TOWNYAR
$HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEIIVERED IN
1146 Rt 28 ACCORDANCE WITH THE POLICY PROVISIONS.
South Yarmouth,MA 02664 �����ESEwrnrne
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�1988-2010 ACORD CORPORATION. All rlghts reserved.
ACORD 25(201�/05) The AGORD name and logo are reglstered marks of ACORD