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Home My WebLink AboutApplication and WC' ` ' ��Ci��D � ' a TOWN OF YARMOUTH BOARD OF HEALT � � APPLICATION FOR LICENSE/PERMIT -201 OC I 1 6 ��6 ...- * Please complete form and attach all necessary documents by Dece�ih 6. Failure to do so will result in the return of your application pac �EPT. � ' ESTABLISHMENT NAME: ��i-a�t�nm 'Av�2. Cr�rn�,�P�,:e<,c,cP TAX ID: � $ ' ' LOCATIONADDRESS:� ��r pyQ.S_�fcxar+c�i+G�. }^�11�.�2�U TEL.#: �0�_-3�&_1�-dc� ; MAILiNG ADDRESS: � (�ni�a-ic�c� ��.a , Fe7s��,�_�te, rr��,f.tV E-MAILADDRESS:_�f;SJ,�!_72»E,-[�_y��.l,Qp.�,o,r�2. ' OWNER NAME: `�Sl-�,L Shu K 1� CORPORATION NAME (IF APPLICABLE): T-�-P�rr, C��-p• MANAGER'S NAME: ,"�j �}j Sh u ic i� TEL.#: �a�_�2�t —3�tty MAILING ADDRESS: � (�c�'��c5 l�ccy �ar�tsl--�QIP. �'Y►� D26�-1 U 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. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their 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. 3. 4. 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 �le at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). 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. 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 file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $55 _TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 _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. $285 VENDING-FOOD $25 �<25,000 sq.ft. $l50 1� _FROZEN DESSERT $40 =TOBACCO $110 �� , NAME CHANGE: $ts AMOUNT DUE _ $ �,60_QO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** z , I i ADMINISTRATION 4 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 � AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR ( WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V 4 , i 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 OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by tlie 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 submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen I�essert 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. OUTDOOR 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 16, 2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, 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:�A-1�� 2016 SIGNATURE: k , ; � PRINT NAME& TITLE: � �S��, -�j ��j��G'. ��(,pZ�Q-�� ! Rev. 10/12/16 • ` � The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ` ' 1 Congress Street, Suite I00 Boston, MA 02114-2017 � www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv Business/Organization Name: �'-�- � �,�^�� pt P _ �h�,r„�o�,r.�e-�,c Address: 1�`,--� �s�� .r�, City/State/Zip:�_uaa rr�u,�-G, , (��,.��64 Phone #: S�Fs- ?,qg.�.So c� Are you an employer? Check the appropriate box: Business Type(required): 1.� I am a employer with�_employees (full and/ 5. � Retail or part-time).* 6. ❑ Restaurant7Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(incl. real estaxe,auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Enterta.inment 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 organizaxion,staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my emp[oyees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage 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 imprisonment,as well as civil penalties in the form ofa 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' ,under the p ins and penalties of perjury that the information provided above is true and correct. Si ature: Date: i o-2 5-l b Phone#: SbFs'-5"21i-?�,,�U Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia � A�� DATE(MM/DDIYYYY) �,,,, CERTIFICATE OF LIABILITY INSURANCE 10/19/2016 THIS CERTIFICATE IS ISSUED AS A MATTER 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 BEIOW. 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 have ADDITIONAL�NSURED provisions or 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 co�fer rights to the certificate holder in lieu of such endorsement(s�. PRODUCER N�E CT Deborah Hathaway � G.H.Dunn Insurance Agency,Inc. 64 Fairhaven Road PHONE ��3ZZ-3Z4Z �aC No�:(508)322-3243 PO Box497 aooRess: deborah@ghdunn.com Mattapoisett,MA 02739 INSURER S AFFORDING COVERAGE Nac u iNsuReRa: MARETAILERS U00000 j INSURED TTeen Corp dba Station Ave Cornenience Paresh Patel INSURER B: ' 457 Station A� South Yarmouth,MA 02664 INSURER C: � INSURER D: INSURER E: � INSURER F: , COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: , �l-NS IS TO CERTIFY l}-WT Tl IE POLICIES OF INSU�ANCE LISTED BELOW HAVE BEEN ISSUED TO TI-IE INSURED fuAMED ABWE FOR TF� POLICY PEPoOD INDICATED. NONVITF�TAt�ING ANY REQUI�EN�NT, 1ERM�COf�DIl10N OF ANY CONiR4CT OR OTl-ER DOClNv1ENT WITH RESPECT TO WHICH THIS CERl1FICAlE MAY BE ISSUED OR MAY PERTAIN, THE INSU�ANCE AFFORDED BY 11-E POLICIES DESCPoBED HEREIN IS SUBJECT TO ALL�l E TERMS, EXCLUSIONS A(�CAf�IT10NS OF SUCH POLICIES.LIMITS SFI0INN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS � COMMERCIALGENERALLIABI�ITY EACHOCCURRENCE $ CLAIMS-MADE �OCCUR DAMAGETOREhfiED PREMISES occurrence $ MED E:�(Any one person) $ PERSONAL&ADV ItJJURY $ � GEIJL AGGREGATE LINYT APPLIES PER: GENERAL AGGREGATE $ POLICY ��T �LOC PRODUCTS-COMP/OP AGG $ OTFER: $ � AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY IIWURY(Per person) $ OWNED SCHEDULED BODILY II�tJIIRY Per accident $ AUTOSONLY AUfOS � � FIRED ��N-OWhJED PROPERTY DAMAGE $ AUiOS OM.Y AUTOS ONLY � Per accident $ � UMBRELLALIAB OCCUR EACHOCCURRENCE $ EXCESS LIAB CLAIMSMADE AGGREGATE $ DED REfENiION$ g � A WORKERS COMPENSATION 01 400050221 61 1 6 Tteen 01/01/2016 01/01/2017 PER OTH- AND EMPIOYERS'IIABILITY AT E ER ANY PROPRIEiOR/PARTNER/EXECUTIVE Y/N . OFFICER/MEMBEREXCLUDED? � N/A E.L.EACHACCIDEPdf $ �,OOO (Mandatory in NH� E.L.OISEASE-EA EMPLOYEE $ �� If yes,tlescribe under ��O . DESCRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Atldltlonal Remarks Schedule,may be attached It more space is requlretl) CERTIFICATE HOLDER CANCELWTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ToWf10f Y8fIT10Uth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE �� O 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD