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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2017 •Piease complete form a�attach all necessary documents by��6.2016. Failure to do so will result in the return of your applicat�on pac et. E5TABLISHMEIVT NAME: LOCATION ADURESS: �N ' 1 TEL.#• - 7 U- 3 3(� MAILING ADDRESS: �� 1 . E-MAIL ADDRESS: R f��2v ��T�S f»' /L. � : OWNER NAME: v�- u b2 t2�o � � Ct?RPORATION NAME(I F APPLICABLE): 12 c✓L A�� E�v7 1l'V i a: MANAGER'S NAME: d U"1� TEL.#: 5G ' q� ,� MAILING ADDRESS: / � '�' POOL CERTIFICATIONS: <� The pool supervisor mast b�certiftai u a�ooi Opetxtor,as reqniral by Stste IAw. Piease Iist the designated p,;.::�u:; Pool Operatot(s)aral attach a copy of tlx cer6fication to this form. ' 1. 2. _:.,....,>� Pool operators must list a m' ' um of two employees currently certi ia staadaid Fust Aid Community Cazdiopul�oaary Resusci ' (CPR),having o�certifiedemp lo on s�at all ' Please list the empioy�s below and cflpies of their certificatrons to this f T6e� t wi�not ase past L� co � Yeaia'records. Yon provide ne�copiea aad muin ' tAe at your place of sivas. � cc�', � L 2. � N � 3. 4. W v � FOOD PROTECTION MANAGERS-CERTIFTGATIONS: � O = All food service establishments are requu�ed to have at least one fiill-time employee who is c;ertified as a Food Prot�6on Manager,as c�fined in the State S�itary Code for Food Service Establishments,105 CMR 590.000. Please attach cogies of certific�tion to this applicarion. The H�aith Depsrta�eat�viii aet�se past yws'r+ecords. Yoa must provide ee�r eepies nnd msintsiu a�at yoar estsWis6mea� ;. 1�C�-�.�u � Tum�tn. 2. � Rtr��� ANS#��irZ, , PERSON IN CHA,RGE: Each food establishment mvst have at least one Peison ln Charge{PIC)on site during hours of optration. i. �11�,11�10111Y) �v� a. TI,�FI- IV�� I�� ALLERGEN CERTIFICATIONS: All food service establishments are required W have at least ane fiill-time employee who hes Allergen certification, as defined in the Siate S�itary Code for Food Service Establishments,105 CMR 540.009{Gx3xa). Please attach copies of certification to tbis a�lication. T4e Iieaith Deparlmest w�i nat nse past years'recards. Yoa mast provide new cspies nnd maietai�a at yo�r eshbhs��ent �. ��►�� 2. �-`Iv���� � HEIMLICH CERTIFICATIONS: All food service establishments with 25 sesLS cx more must have at l�st one employee trained in t�e Heimlich Maneuver on tbe pr�mises at all times. Please list your em�ployees trained in auti-choking proc�dures below and attach copies of employee ceitific;ations w this form. TLe Health l�arte�ent w�7t eot�e p�st yeara'raorda. Yon mast provide new copi�a aad maiahie s Sk at yoar place of basine,�s. i. nv �1�4C�'�Cf� a. TI r rAl'�-I (Zvv 3. 4. RESTAURANT SEATING; TOTAL# � i.onGnvc: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT� LICENSE REQUIRED FEE PERMiT# LICENSE REQU[RED FF� PERMiT# 88c8 S53 CABIN Si5 _MOTEL 1110 �► S35 CAI� SSS _SWIADNINGPOOLSIlOea �1.OD(�E S53 —=1RAILER PARK 5105 �VHIRLPOOL S110p. FOOD SERVICL• LI�CENSE FEE � LIC�S��D � PERi�llT�Y LI��O UJRED � PERMff N a�oo���D sizs �� � >l�$�T$ �� �C���N vJC. �) ��� �jA1.F_CAI.R �$Q RETAII.SERVIC�: =RESID.KTfCHEN SSO LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT#I LICENSE REQUIRED FEE PEWNIT N <50sq R� . SSO . >25,000 ft. 5285 VENDING-FOOD t24 =Q5.000 sq.ft. f130 =FROZEN�SERT f40 �TOBACY:O SI10 rurt�cHnrrcE: s�s AMOUNT DUE = S_(S5.0o ••.ssPy���J�OVER AND COMPLETE OTHER SlDE OF FORM*•►•" ADA�llNISTRATION Under Chapter 152,Section 25C,Snbseetion 6,the Town of Yarmouth is now required to hold issctffiee or renewal of any license or permit to operate a business if a peison or company dces not have a Certificate of Worker's Compensation Insuraace. 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 ta�ces and liens must be paid ,'or to renewal or issuance of your permits. PLEASE CHECK t c p�i APPROPRIATELY IF PAID: + / YES v 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 temporaiy and short term occupancy,ordinarily and customarily associated wiih motel aad hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of rasidence elsewhere.Transient axupancy shall generally referto contin�us axupancy of�t more than thirtY(3U)days.and an aggregate of not more thari ninety(90)days within any six(6)mouth periad. Use of a guest writ as a residence or dwelling unit shaii 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 annended,shall generally be considered Transient. POOLS POOL OPEI�TING:All swimmiwg,wading and whirlpools which have been cl�i for the season mvst be inspected by the Heaith Deparhneut prior to o enwg. Contact the Health D�epartrnent w sc6edak t6e L�on�ree(3) days prior to ope�ing. ASE O :People are NOT allowad to sit in the pool azea until pool has been inspected and oPencd• POOL WATER TESTTNG: The water musc be tested for pseudomonas,totat coliform and sta�dard plate cowrt �ea�S�certified lab,and submitted to the Hcalth Deparm�ent three(3}days prior to opening,and quarterly POOL CLOSING:Every outdoor in groand swimming pool must be drained or covered withiu seven(�days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: Ali food service establishments must be iaspected by t�Health Depertment prior to opeai�g. Please contact tl� Health Department to schedule the inspection three(3)days prior to opelung. CATERING POLICY• Anyo�who caters within the Town of Yarmouth must norify the Yarmouth Health Department by fil' the reqwred Temporary Food Service Application form 72 hours prior to the catered event. These forms c�an be obtai�d at the Health Depa�nent,or fmm the Town's website at www.yannauth.ma.�wnder Health Departrnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening a�monthly thereafter,wiW sample results submitted to the Health Department. Failnre to do so wilt result in the suspension or nwocation of your Frozen Dessert Permit tmtil the above tetms have bcen met OUTSIDE CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must l�ave prior approva!from the Board of H�Ith OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is proLibited. NOTTCE:Permits nm annoally from January 1 to Dax�nber 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOYATIONS TO ANY FOOD ESTABLISFIl4tENT, MOTEL OR POOL (i.e., PAIIVTIIVG, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROYED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY N. ' DATE: � SIGNATURE: ' PRINT NAME&TITLE: ���I V U()U'� Y`U ��9�i�C9-1. \ � Rev.IQl12/16 '4C4 OR � CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) � 10/20/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT APFIRMATIVELY OR NEGATIVELY AMEND,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 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 terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. . PRODUCER Benson Young&Downs Ins CONTACT Kathy Jones 565A Route 28 PHONE . (508)432-1478 F"X .(508)430-1532 P O Box 158 E�A�� kathyjones@byandd.com Harwich Port MA 02646-0158 NSURER FORDIN VERA E NAIC i i RERA:Hartford Fire Insurance Company 19682 INSURED R B. Raymond C.Roy and RCR Management Inc Salty's 540 Main Street,Rte 28 R � West Yarmouth MA 02673- COVERAGES CERTIFICATE NUMBER: 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. NOTIMTHSTANDING 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. � INSR 7ypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP '��, LIMITS � COMMERCIAL GENERAL LIABILITY � I EACH OCCURRENCE � CLAIMS-MADE C�OCCUR I, D�GE TO RENTED $ � I '��MED EXP An one erson ''�,. PERSONAL8ADVINJURY $ ��'' GEN'LAGGREGATELIMITAPPLIESPER: I'� I�GENER4LAGGREGATE j � t POLICY�PRO- � '. JECT �OC . I PRODUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY � � I, �!COMBINED SINGLE LIMIT $ ANYAUTO ����.� BODILY INJURY(Per person) $ ALL ONMED SCHEDULED � AUTOS AUTOS �'� �BODILY INJURY(Per accident) $� HIRED AUTOS AU�TOS�ED ',. PROPERTYDAMAGE $ � ' $ � UMBRELLA LIAB OCCUR I I EACH OCCURRENCE $ EXCESS LIAB II '�CLAIMS-MADE I�i 'AGGREGATE $ A wor�cERSCOMPENsaTION OHWECKH277O IO5/1H/2016 5/1H/2017 'X ,PER OTH- AND EMPLOYERS'LIABILITY YYYlllNNN ANYPROPRIETOR/PARTNER/EXECUTNE � � E.L.EACHACCIDENT $ �OO,OOO � OFFICER/MEMBER EXCLUDED? N/A ' (Mandatory in NH) I� ��!E.L.DISEASE-EA EMPLOYEE $ ��0,�00 If yes,describe under '� ' 500,000 E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 107,AddiGonal Remarks Sehedule,may be attached N more spaee is required) Seasonal Restaurant located at 540 Main Street(Route 28),West Yarmouth,MA 02673. Workers Compensation coverage is not provided for Ramond C.Roy. O�� 2 � zp'� HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION AI 008455 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOwn of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 South Yarmouth MA OZ6F)4- AUTHOR¢ED REPRESENTATIVE �/'� ♦ 1/ �.r O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD