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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 December 16 2016. �°� Failure to do so will result in the return of your applicat�on pac et. ESTABLISHMENT NAME: o✓ T � LOCATION ADDRESS: .5— e �'t oK� �— TEL.#: Sa��39�� '�1�D MAILING ADDRESS: � E-MATL ADDRESS: �.c��'✓cre✓{,�►+�f•C oti.^ OWNERNAME: � � .av1'3r CORPORATION NAME(IF�j PLICABLE : �' �E' e�Y.ry►ei LL MANAGER'S NAME: d�'1/I'�^ �i�nS L.#: 5� ' S1l!`S`��5� MAILING ADDRESS: S.�i,�.� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as reqaired by State law. Please iist the designated Pool Operator(s)and attach a eopy of the certification to this form. 1. 2. �r � -�� .� r'�' �� Pool operators must list a minimum of two employees currently certified in standazd First Aid and Community �;',� � h°',� Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the � �• N �° °� employees below and attach copies of their certifications to this form.The Health Department will not use past ;� � years'records. You mnst provide new copies and maintain a file at your place of business. � r=� N ` ` �:� p g,:: i 1. 2. �`� � �cg� 3. 4. r � FOOD PTtOTECTION 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 wilt not use past years'reeords. > You must provide new copies and maintain a file at your establishment. L � l�/L' ��1�jj� 2. /J.�-��+9r�n�. �cc.i/►f O � �. PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � 1. ✓�C✓-�t /�-+ �U r�f G�'�,i 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 appiication. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. �'/ �C/.1.�l-s-o�/��,� 2. HETMLICH 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-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'recorda. 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 REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B S55 CABIN $55 MOT'EL 5110 [NN S55 CAMP $55 SWIMMING POOL$110ea. _LODGE S55 T[tAILERPARK $105 _WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQ UIRED FEE RMIT� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEA'1'S 5125 �Q$(�j CONT[NENTAG $35 NON-PROFIT S30 >!00 SEATS $200 �COMMON VIC. $60 � =WHOLESALE S80 —RESID.KITCHEN S80 RETAII.SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE R£QUIRED FEE PERMIT# <50sq R. $50 >25,000 sq.ft. 5285 VENDING-FOOD S25 =<25,W0 sq.ft. $150 �80ZEN DESSERT $40 �(i p =TOBACCO S110 NAMECHANGE: $15 , • AMOUNT DUE = S �5-DO **t*'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"•*• 80��(306-02 , 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 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 INSURANCB ATTACHED_� OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES 0� 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 sha11 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 ciosed for the season must be inspected by the Health Department prior to opening. Contact the Health Depardnent to schedule the inspectian three(3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool azea 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 Staze 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 Departtnent,or from the Town's website at www.yannouth.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 Heaith Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above teims have been met. OUTSIDE CAF�S: 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 estabIishment is prohibited. i ' NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RET[JRN ; 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 RE RE A SITE PLA DATE:� - au�(� SIGNATURE: �C�G�—� � ', PRINT NAME&TITLE: p>(l� �• �/9'�3 ��i^�'� Rev.10/12/16 i � The Commonwealth of Massachusetts Department of Industrial Accidents O,fface of Investigations � 1 Congress Street,Suite 1 DO Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses A�alicant Information Please Print Legiblv Business/Organization Name: �ya,�e �,� �i1/��/� �L�� Address: � �t✓a��'e ��o v�U ��Ci City/State/Zip: S � r��a� 1�1� yPhone#: S'a j� � 3�1 S�� 1��0 Are you an employer?Check the ap priate boa: Business Type(required): 1.� I am a employer with�mployees(full and/ 5• ❑Retail or part-time).* 6. �RestaurantBaz/Earing Establishment 2.❑ I am a sole proprietor or parmership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we ha�e 1 d.❑ Manufacturing no employees. [No workers' comp.insurance required]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.� Other •Any applicant that checks box#1 must also fill out the secrion 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 providittg workers'compensatlon insurance for my employees Below is the poltcy information. Insurance Company Name: �GG.�r� � d 1"�c�( �v�5�,�� Insurer's Address: 9 73 _L �i�rr+a�c,�" �� !J• �a�X /99� City/State/Zip: ��.�rnr��.� � �G� D�-`� �0 4� Policy#or Self-ins.Lic.# lvL�S��d S D�� 99�/G� //4' Expiration Date: 5��ao17 Att�ch a copy of the workers'compensation palicy declaration page(showing the policy number and egpirntion 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 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�ice of Investigations of the DIA for insurance coverage verification. I do hereby certify,un er the pains and penalties ofperjury that the information provided above is true and correc�t. Si D Phone#: ' 0 ' S� Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cterk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ww�v.mass.gov/dia Client#:45428 2CCCR1 ACORD�, CERTIFICATE OF LIABILITY INSURANCE °ATE`MM'°°"�,", 10/25/2016 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 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 NAME: Dowling&O'Neil Insurance Ag a�";,E,�,508 775-1620 ac,No: 5087781218 973 lyannough Rd, PO Box 1990 E-MAIL Hyannis, MA 02601 ADORESS: 508 775-1620 INSURER(S)AFFORDING COVERAGE NAIC# wsuReRn:Safety Indemnity INSURED INSURER B:ASSOCIBt@CI ECIIpIO�/@PS It1SUP8flC@ Cape Cod Creamery, LLC 5 Theatre Colony Road INSURER C: South Yarmouth, MA 02664 �NSURER D: INSURER E: INSURER F: 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH�CH 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 TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR NND POLICY NUMBER MM/DD MM/DD A GENERALLIABILRY BMA0019440 5/01/2016 05/01/201 EACHOCCURRENCE $� ��QD X COMMERCIAL GENERAL LIABILITY PREMISES Ea occur ence $1 OO,OOO CLAIMS-MADE �OCCUR MED EXP(Any one person) $��,�� PERSONAL 8 AOV INJURY $'I�OOO,OOO GENER,4LAGGREGATE $Z,OOO,OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $Z�OOO�OOO POLICY PR� LOC $ JECT AUTOMOBI�E IIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERSCOMPENSATION WCC50050119952016A 5/01/2016 05/01/201 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY T RY L M ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $��OOO�OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $��0�� If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $��OOO�OOO DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,AddiUonal Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHORIZED REPRESENTATIVE '`�'�-�--� `c'=�.�,�,' --_��'�► O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S179159/M179158 LS1 Client#:45428 2CCCR1 DATE(MM/DD/YYYY) i ACORDTM CERTIFICATE OF LIABILITY INSURANCE 10/24/2016 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 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 C NT NAME: Dowling&O'Neil Insurance Ag PHONE 508 775-1620 F 5087781218 A/C No Ext: A/C No: ' 973 lyannough Rd, P0 Box 1990 E-MAIL Hyannis,MA 02601 ADDRESS: 508 775-�GZO INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Llb@Pt)/MUtUBI INSURED INSURER B:ASSOC18t@CJ Et17pI0�/@fS I11SUf811C@ Cape Cod Creamery, LLC 5 Theatre Colony Road INSURER C: SouthYarmouth, MA 02664 �NSURERD: INSURER E: INSURER f: 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. NOTWITHSTANDING 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, EXCIUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OP INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS lTR INSR WVD POLICY NUMBER MM/DD MM/DD A GENERAL LIABILITY BZS1756129830 5/14/2016 05/14/201 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $3OO OOO CIAIMS-MADE �OCCUR MED EXP(My one person) s 15 000 PERSONAL 8 ADV INJURY $� OOO�OOO GENERALAGGREGATE $Z�OOO�OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $Z�OOO�OOO POLICY PR� LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peraccident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERSCOMPENSATION WCC50050119952016A 5/01/2016 05/01/201 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y�N 1 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $'I OOO OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) E.l.DISEASE-EA EMPLOYEE $� OOO OOO - _ -- --- ----- --- - __ -- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $�,OOO,OOO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additlonal Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Yarmouth R�CE'�� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth, MA 02664 pCT � � �njs AUTHORIZED REPRESENTATIVE HEALTH DEPr ..�,�,,,,,,,,�. G C:. -""-'�"•'„� O 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S179091/M179089 LS1