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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by�mber I6 2�16. Failure to do so will result in the retum of your applicauon pac e�— ESTABLISHMENT NAME: t 3� LOCATION ADDRESS: 'TEL.#: 3/// MAII.ING ADDRESS: YVf'1 E-MAIL ADDRESS: 1 L 'L�, � OWNER NAME: GL. CORPORATION NAME(IF ApPLICABLE): G i C3 �G • MANAGER'S NAME: Q D t'Tl TEL.#: D = � �j MAILING ADDRESS: � � � � n POOL CERTIFICATIONS: _ � � The pool supervisor must be certifted as a Pool Operator,as required by State law. Please list the designated p � � Pool Operator(s)and attach a eopy of the certification to this form. � `� � 1. 2, 'i � C7 Pool operators must list a mntimum of two employees cwrendy certified in standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified em�ployee on premises at all times. Please list the employees below and attach copies of their certifications to this form.T6e Healt6 Depsrtment will aot asa past years'records. Yoo muat provide new copies and maintain a file at your place of bnainess. 1. 7. 3. 4. �:. L� FOOD PROTECTION MANAGERS-CERTIFICATIONS: �;� All faod 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 certificarion to ttus application. The Health Department will not uee past years'records. �j,'` You must provi de new copies and maintain a Sle at yonr establiehment. 1.�(,`�t,(',r„1 e 1'ta�?�i 2. , PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. `7�1 Q��rP I�.�� 2. �s'�'i%�-- �l[t'C�r2�� ALLERGEN CERTTFICATIONS: All food service establishments aze required to have at least one fWl-time employee who has Allergen certification, as defined in the State Sanitary Cale for Food Service Establishments,105 CMR 590.009(Gx3xa). Flease attach copies of certification to this application. The Health Department will not use past yeara'records. You must provide new copies xnd maintain a file at your eatabli�hmen� 1. ��1��C��?.!�!''��l� 2. HEIIviLICH CERTIFICATIONS: � All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich �n�� Maneuver on the premises at all times. Please list your employees trained in anti-chokxn�procedures below and � I� attach copies of employee certifications to this form. The Health Department will not nse past years're�ords. You mnst provide new copies and msintain a file at yonr place of huainess. ' I_� �/\'/�/r ( a � 1. J IA._1' • W�L� l.��,I�CA� � 2, � 3. 4• �� . RESTAURANT SEATING: TOTAL# Qf�� r OFFICE USE ONLY LODGIIVG: LICENSE REQUIRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� SSS CABIN sSS MOTEL S110 �� SSS CAMP $55 =SWiMMING POOL Si l0ca L.�DGE S55 �I'RAILERPARK S103 _WHIRI,POpL S110ea FOOD SERVICE: LICENSE REQUIRED FEE R��# LICENSE REQUIRED FEE PERMIT# LICENSE RE UlRED FEE P@RAR'f# �0.100SEA'f'S 5125 �7"vG�j CONTINEIVI'pL S35 NON-PRO�IT S30 >I�SEATS 5200 �COMMONVIC. E60 �/� =WHOLESALE S80 RETAIL SERVICE: —RESID•KITCHEN S80 L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LIC£NSE REQUIRED f'EE PERM]T# <50sq ft. S50 >25,000sq R S285 VENDING-FOOD S25 _<23>OOOsq.R. SISO � =FROZENDESSERT S40 TOBACCO SI10 NAME CHANGE: S15 AMOUNT DUE _ � �$S,QQ •*"•PLEASE TURN OVER AND COMPLEIIC UTHER SIDE OF FORM**'•" i r ADMINISTRATION 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 dces 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 renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTI�R LODGING ESTABLISHMENTS TRAI�JSIENT OCCIIPANCY: For purposes of the limita6ons of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinarily and custoraarily 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 mone 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 tlie collection of Room Occupancy Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as arnended,shall generally be considered Transient. POOLS PQUL OPENIIVG:All swunming,wading and whirlpools which have been closed for the season must be inspected by the Hea1th Department prior to opening. Contact the Health Dep ent to schedule the inspection tLree(3) day�prior to opening.PLEASE NOTF:People are NOT allowed o s�it in the pool area until the pool has been inspected and opened. POOL WATER TESTTNG: 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 quarkerly thereafter. ' POOL CLUSING: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.pected by the Health Deparnnent prtoe to opening. Please contact the Hea1th Department to schedule the inspect�on 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 reqwred Temporary Food Service Application fortn 72 hours prior to the catered event. These forms can be obtained at the Health Department,or from the Town's website at www.yazraouth.ma.us under Health Deparbmettt, Downloadable Forms. FRt)ZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sannple 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Baard of Healtt�. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or foad service estabiishmettt is prohibited. NOTICE:Penmits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DEGEMBER 16,2016. ALL RENOVAI'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINi'ING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF TH PRIO � TO COMME CE NT. RENOVATIONS MAY RE SITE P AN. " DATE: � SIGNATURE: G�Z.�// - PRINT NAME&TTTLE: � Rev.1�17l16 _�. � The Commonwealtti of Massachusetts Depantmcnt of Industrial Accidents Office of Investigations ' 1 Congress Stree�Suite 100 Boston,MA 02114-2017 www muss gov/dia Workers' Compensation Insurance A#�idavit: General Businesses Annlicant Information Please Print Le�iblv Business/Organization Na.me: �• . � , aaa��s: D Z� . Z� City/State/Zip: ' e( y��-�7/l�t� Ph ne#: �0 �v9�3`�� e you an emptoyer?Check the appropriate boz: Business Type(required): 1. am a employer with�employees(full and/ �• ❑Retail or part-time).* 6. �Resta.urantlBar/Fating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � pff��a/or Sales(incl.reai estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] g. �Non-profit 3.❑ We are a corporation and its of�icers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.�Manufacturing no employees.[No workers'comp.insurance required)• 11.�Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. jNo workers' comp.insurance req.] 12.[]Other 'Any epplicffit that checks box#1 must also fill out the secti�below showing iheir workers'compensation policy informatiot►. ••If tLe corporate officers have exempted themselves,but the corporati�has ott�r employees,a workers'oompensation policy is tequired and such an organizati�should check box#1. I am an employe�that isprnviduig workers'comperrsatdo rnsu�once for my employee� Below is thepolicy informatiori. id' Ilzsurance Company Name: �dC�"D�ic.� �/u(�� Gl��iC__ Insurer's Address:��- j!�Yt.P�,j L�� • City/StatelZip: �� Z�Z�Q Policy#or Self-ins.Lic.# L�� (�7�7��" Eacpiration Date: S � Attach a oopy of t6e workers'compensation policy declaratian page(showing the policy namber nd ezpiration date). Failure to secure eoverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonrnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to�250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of�ce of Inves6gations of the DIA for insurance covera.ge verification. I do kereby ce , n the pains and penaltfes oJperjury that tJ'ie 3nformatlon provided above�s tru and conec� ^ i � / P�one#: Sdb 7 7Ct'OZ�y� — �S"l�� 39'�/'3///- S`�Dd� 73��//� O,fj rcial use only. Do not write ln this area,to be completed hy c3ty or town officiq!! City or Town: Permit/License# Issning Authority(circle one): 1.Board of Health 2.Buildiag Depsrtment 3.Citq/Town Cterk 4.Licensing Board 5.Selectmen'a Office b.Other Contact Person• P6one#• www.mass.gov�aia � ,�c Ro�n� CERTIFICATE OF LIABILITY INSURANCE °"�'"M'°°""""' il/4/16 THS CERTiFICATE IS ISSUED AS A MATTER OF If�ORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE HOLDER THS CERTiFICA7E DOES NOT AFFlRMA'IIVELY OR NEGATIVELY AMEND, EXTEI�D OR ALTER TF� COVERALaE AFFORDED BY THE POLJqES BELOW. THS CERTIFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUNG INSURER(S), AUrHOWZED REPRESEM'A71VE OR PRODUCER,AND THE CERrIFlCATE HOLDER. IMPORTANT: If the certifiCate hdd�is an ADDI't10NAL INSURED,the policy(es) must be endorsed. If SU�iOGATiON IS WAIVED,subject to the terms and conc�tions of the policy,certain policies may require an endorsement. A stabement on this certificate dces nat coni�ri�ts to fhe certificate holder in lieu of such endcxsernen �oouc� Pike Iasurance Agency, Inc. PtqNE T r�►x 8 Main Street E-�a� ' S08) 255-7880 N : (5oa� 24o-29oa nnoeess: info@ ikeinsuraace.com PO SOX 2743 �� S AFFORDtNO COVERAGE NAIC# Orleans, MA 02653-241 i�R�A:Norfolk � Dedham Mutual Fire I ��ED irsua�a e:Hos italit Mutual Insurance C Gerardi's Cafe Inc. ,�R�c: 902 Main St INSURER D: S. Yarmouth, MA 02664 ��RERE: ItiSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMm ABOVE FOR THE POLICY P�tIOD INDICATED. NQTIMTHSTANDWG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS CERTIFICATE ML4Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TI-E POLICIES DESCRIBED HEREW IS SUBJECT TO ALL THE TERMS, EXCLUSI�IS AND CONDITIONS OF SUCH POLIC►ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. � IN AODL SUBR POLICY EFF POIlCY D� LTR TYPEOFINSURlWCE POLI(.Y WI+BER MIOD/Y A/il/DdYYYY �II�'fS GENERAt-uAB�LJTY EACHOCCU�tENCE 5 CONMERCIALGEPEPo4LLIABIUTY DAMAGETORENTED j CLAIMSaNADE �OOCUR NED D�(Ary one persm) $ PERSON4L&ADV IN.MIRY $ GENERAL AGC�REC,ATE $ GEN'LAGGREGATE LMAITAPPLIES PER PRODUCTS-CONP/OP AGG $ POLICY PRO- L� $ AUTOMOBILE LIA&UTY C a accidert GL LB�Aff $ ANY AUTO BODILY INJURY(Per person) $ ALLOWPED SCHEDULED BODIIYINJURY(Peracadent) $ AUTOS AUTOS NON-OWNED PROPEIZfY DAAN4GE $ HIREDAUTOS _AUTOS eraccident $ UNBF�LLA uAB OCCUR EACH OCCUW2ENCE $ D(CESSLIAB CLAIMSauIADE AGGREGATE $ DED RkTENI'ION A �K�� WE077044A 5/19/16 5/19/17 WC STATU- OTH- ANDEM�OYERS'LU181LJTY Y!N AN1'PROPRIEiDR1PARTNERlE7�CUTWE E.L.EACHACqOENf $ IOO OOO OFFICEWMEt�ER IXCLIAED? � N/A (Mandabry in NH) EL.DISEASE-EA BuPLOYE $ lOO,OOO If yes,describe under DESCRIPTION OF OPER4T70NS bebw EL.DISEASE-POLICY LNNff SOO OOO B Liquor Liability 00078582LL 5/14/16 s/i4/i� 1,000,000 2,000,000 OESCRIPTIONOF�ERATiONS/LOCAT10N5/VB�CLES (AttaehACORD101,Ad�onalRerrerka5ched�Ae,"rfmorespaceisreq�ired) CERTIFICATE HO�DER CANCELLATION SHOULD ANY OF THE ABOVE DESCRiBED POLICIES BE CANCELLED BEFORE TFE EXPIRATION DAiE THEREOF, NOTICE WILL BE DELJVERED Bd TOWA Of Yarmouth AOCORDANCE WIiH 7HE POLICY PROVISIONS. Attn: Linda Sall Licensing 1146 Rte ZH AV��TA� 3 Yarmouth, MA 02664 Janice M. Skinner O 1988 2Q10 ACORD CORPORATION. Ail rights reserved. ACORD 25(201 N05) The ACORD rmme and logo are registered marics of ACORD Phone: Fax: E-Mail: ilkovich@hotmail.com