HomeMy WebLinkAboutApplication and WC a�-YMPIF} .
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� ► TOWN OF YARMOUTH BOARD OF HEALTH
i � � APPLICATION FOR LICI:N�E/PERM�T -20 �: �jU�l •� $ ?��B
� � ��6�' -
�"` * Please complete form and attach all necessary documents.by " ' ber 16 2016.
Failure to do so will result in the return of your application ck�.Eq�TH ���T
ESTABLISHMENT NAME: OL`l�"�P�� SH- cJ E T�J T TAX ID: � �2S193C�g
LOGATION ADDRESS: 13�kt Q�- 2$� �ou�ct��f�2.M0�1�. MR �Z..���f TEL.#: 5o8-3q�f-Z� I'Z
MAILING ADDRESS: SA-N��
E-MAIL ADDRESS: �
' OWNER NAME: i��E'tYZE Ska�2DA3
CORPORATION NAME (IF APPLICABLE): G�y M Pr►� Ftsl� �'oUbt� I�T�-A�NT lN��
i MANAGER'S NAME: TEL.#:
MAILING ADDRESS:
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.
_ _- - - --
-- -- _ _ _---_ _ _ . — -- ----- - _-- __--
-- --- _ _ — _
__ __. -- -..� ----�:
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 file 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# 4�0 �
� OFFICE USE ONLY
;—__ �,��r��--- —-- � .� _.
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEB PERMIT# LICENSE RF(2UIRED FEE PERMIT#
� B&B $55 =CABIN $55 =MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea.
I LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $ll0ea.
j FOOD SERVICE:
LICENSE REQUIRED FEE P RM LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 (7�� CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $200 =COMMON VIC. $60 �2.7 WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
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. $150 _FROZEN DESSERT $40 TOBACCO $110
NAME CHANGE: $is AMOUNT DUE _ $ �$S. OQ
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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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 iNSURANCE ATTACHED
�R !
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED �
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK i
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
. _._ _ __ i
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be E
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 I
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. r
�
POOLS
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the 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 SERVI'iiCE __` : _ i
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.varmouth.ma.us under Health Department, i
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
Dessert 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 COOHING:
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
_ _ _ _.- __ . .. _ - f
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 E
TO COMMENCEMENT. RENOVATIONS REQUIRE ITE�AN.
DATE: SIGNATURE:
PRINT NAME & TITL :
Rev. 10/12/16
„� ,
' ” � The Commonwealth of Massachusetts '
Department of Industrial Accidents '
office of Investigations ��(�(� ��:/ v �
` ' I Congress S tree t, Sui te I 0 0
, Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses ;
� Applicant Information Please Print Legiblv
Business/Organization Name:
Address: ',
City/State/Zip: Phone #:
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. ❑ RestaurantlBar/Eating Establishment '
l. 1 am--a sole proprietor or partnersnip an nave no `– --~— - - - "
7. Offic�o�a j'�e�"i=i�'a"�-�s'�f'e`;a�zto, 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. ❑ Entertainment
their right of exemption per a 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: [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 o�cers have exempted themselves,but the corporation has other employees,a workers'compensation poliey is required and such an
organization should check box#1.
I am an emp[oyer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: �
Insurer's Address:
City/State/Zip:
j Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
! fir,e up ta�t,�O�.GG air�lor onz-year imprsotln��nt,as w'�Y�e �s�iv1,p�ri�iti��in t�e foritr-�f'a�'�f'6r`��(3��R atr�a fiTi�
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 I do hereby certify under the ains and penalties ofperjury that the information provided above is true and correct.
i
ature: Date:
Phone#:
j Official use only. Do not write in this area,to be completed by city or town officiaL
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City or Town: Permit/License#
i
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
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A�oR�'u CERTiFICATE OF LIABILITY INSURANGE DATE(MMIDDtYYYYy
03/13/2017
THIS CERTIFICATE IS lSSUED AS A MATTER OF tNFORMATION 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
SELOW. THIS CERTIFiCATE OF INSURANCE DOES NOT CONSTl7UTE A CONTRACT BETWEEN THE iSSWNG INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTRNT: If the certificate holder is an ADDITIQNAL INSURED,the poticy(iesj must ba endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain poficies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in tieu of such endorsement(sy.
PRoouceR Phone:617-926-4000 C N ACT
Guard Insurance Agency NAME_
—.------ ----�
279 Mt.Auburn Street Pax:Fi17-926-8334 PN"c°Nno�_____________________f�c,No�_____
Watertown,MA 02472 e-r�a�� — ---------
A�DRESS:
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___ INSURER�S)AFFORDING COVERAGE ! NA1C#
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�r,suReRa:Hospitality Mutuat Ins.Co. __ ______ ; _ _
INSURED Otympia Fish House Restaurant �r,suReR e:
Inc dba Olympia Restaurant -- ------- ---- ------= ----
9341ARaFnStRte28 ,n,suRsxc: ------ ------ ` --
S.Yarmouth,MA 02664 INSURER D:
----- ----------------',-----
INSURER E:
INSURER f:
COYERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POtICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED T4 THE INSURED NAMED ABOVE FOR THE POLICY PERIOQ
tNDICATED. NOTWITHSTANDING ANY REQU442EP}AENT,TERhM1 OR COTSD1TfO1S Of A13Y CONTRACT OR OTHER DQCUMENT WITH RESPECT TO UVHICN THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAtN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS,
EXCLUSiONS AND CONDiTiONS OF SUCH POLlCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
-------------------�- ---------------_—,
W SR! /1DDL aU�§R ---- POLICY EFF j POLICY EXP i
L7R � TYPE OF INSURANCE ( J pOLiCY NUMBER ;MNi/DDIYY MMllDD7YYYY i LIMITS
! GENERAL LIABIUTY � � i i � '
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j ;COMMERCtAL GENERAL UABIIiTY ! � � , ������b�NTED �
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i GEN'l AGGREGATE LIM1T APPLIES PER: � I � � #� �PRODUCTS-COMP/OP AGG �5
i i POLfCY i �PRO- � j LOC I i { t f - --�—��S --
;AUTOMOBILE LIAB�LITY � % � { , 4 COMBINED SM LE LIMiT �
a- } � � , Ea accident) �5 __
f s ANYAUTO � j � j � �BODILY INJURY(Perperson) j S
� -�ALL O'JVUEO ` SCHEDUIED � � ' ` �--
-----
'_!AUTOS �'AUTOS [ � �.; � � � 80DILY INJURY 1Per accident)�5
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f j � �NON-0WNED j i i i ° ; PROPERTY DAMAGE
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HtRED AUiOS i AUTOS ' ' � ' �
f—�; r-� � ; { � � � Per acadeniL_ ;
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1 ' I is
; { UMBRELLA LIAB I �OCCUR � ' 1
�__j � I j � .EACH OCCURRENCE f$_ ___
_ y EXCESS LIAS _ �CLRIMS-MA�Ej ; j i � LAGGREGATE �_S
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WORKERS COMPENSATiON ! ! � ' I i WC STATU- sOTH-!
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�ANY PROPRtETORlPRRTNER/EXECUT�VE j I ! E�.EACH ACCIDENT 'y
� OFFtCER1MEM8EREXCWDEO? N/A, � - '
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' (Mandatory in NH} � ; }E L DiSEASE-EA EMPLOYEE�S
i if yes,descnbe under l � ---- •-----�------
���pESCRIPTION OF OPERATIONS below � } � E.L.DiSEASE-POUCY LIMIT;5
A 'LIQUOR LfABtLITY � �00055642LL i 03102/2017�03t0212018 IPER OCC 1,400,00
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DESCRIPTION OF OPfRATIONS/LOCATIONS 1 VEH�CLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required►
RESTAURAt3T
CERTIFIGATE HOLDER CANCELWTION
YARMOUT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE
YARMOUTH TOWN HALL THE EXPIRATIpN DATE THEREOF, NOTICE WILL BE DELIVERED IN
1146 ROUTE 28 ACCORDANCE WITH TME POUCY PROVISIONS.
S.Y/QRNlO!lTN,M�Q O28&4
AUTHORiZEO REPRESENTATIVE
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O 1988-2010 ACORD CORPORATION. Ail rights reserved.
AGORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
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`4C`�' CERTIFICATE OF LIABILITY INSURANCE 3i2 i2Doi�� -
THIS CER7IFICATEIS 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,tl�e policy(iesj must have ADDITIONAL INSURED provisions or be endorsed.
if SUBROGATION IS WAIVED,subject Uo the terms and conditions of tfie policy,certain policies may require an endorsement A statement on this
cerlificate does not confer ri hts to the certificate holder in lieu of such endorsemen s.
vaooucm corrrAcr
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NUMBER ONE INSURANCE AGCY INC/PHS ac°,"ri,��>: (866) 467-$730 ��.Nor: (888) 443-6112
088171 P: (866) 467-8730 F: (888) 443-6112 ��5:
3O1 WOODS PARK DRIVE INSURER(S)AFFORDINGCOVERAGE NNCM
' CLINTON NY 1.3323 wsueeaa: Twin City Fire Ins C
/�� � � � � INSURERB: � � � . .. . � . . . . .
� � . INSURERC: � � . � �
OLYMPIA FISH HOUSE RESTAURANT, INC. iNsuaeao:
13'Yl ROUTE ZU INSURERE:
SOUTH YARMOUTH MA 02664 msuReaF_
� COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
� THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAV� BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITNSTANDING ANY R�QUIREMENT, T�RM OR CdNDfTION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 7HE POLICIES DESCF2IBED HEREIN IS BUBJECF TO ALL THE
TERMS,EXCLUSIONS AND CONDff IONS OF SUCH POLICIES.LIMffS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
� �WSA � TYPEOFINS(1RANCE ADD Si/B � POLICYNUAISER POLICPEFF POLICYEXP . . .y�� : . �
COMMERCIAL GENERAL LIABIL7TY EACH QCCURRENCE g
CLAIMS-MAQE ❑OCCUR DAMAGE TO RENTED $
PREMISES(Ea occurrence)
MED EXP(My one person) g
PERSONAL&ADVINJURY g
GEN'L AGGREGATE LIMIT APPlIES PER GENERAL AGGREGATE $
POLICY� PR�'❑LOC PRODUCTS-COMPIOPAGG $
JECT
OTHER: S
AUTOMOBILE LJABILRY COMBINED SINGLE LIMIT S
(Ea accident)
ANYAUTO BODILYINJURY(Perperson) g
OWNED SCHEDULED BODILY INJURY(Per acciderrt)g
AUTOS�NLY AUTOS
HIRED NON-0WNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY (Per accideM) , $
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE g
EXCES3 LIAB CIAIMS-MADE AGGREGATE $
DE RETENTION$ � � � � � $
W06iL'86COMPENSATKIN � PER � � OTH- . .
ANDEsifPlOY�85"L7A6II.TTP � 'X STATUTE ER �
ANY PROPRIBTOR/PARTNER/EXECUIIVEY/N E.L.EACH ACGDENT s�d O� O O O
OFFICERlMEMBER EXCLUDED?
A (MandatoryinNH) ❑ wA 08 WEC TJ3961 04/19/2017 04/19/2018 E.L.DISEASE-EAEMPIAYEE$lOO� ���
If yes,describe under E.L DISEASE-POUCY LIMIT $rj Q Q� Q Q Q
DESCWP710N OF OPERATIONS below - � �
DESCR/PTION OFOPERAT/ONS/LOCATlONS/VEHfC�,S)RD 101,Add'rtional Remarks Scbadula,may be attaahad if more spaco is raquired)
Those usual to the Insured's Operations.
_;_;:-�:
_..._.:.
CERTIFICATE HOLDER CANGELLATION °�°
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED
Health Divis ion BEFORE THE EJCPIRATION DATE THEREOF,NOTICE WILL BE
DELIVERED W ACCORDANCE WITH THE POLICY PROVISIONS.
Yarmouth T own Ha l l AUTHOR/ZED RFPRESEMA77VE 4
114 6 ROUTE 2 8 ��, '�'��,1 f�„�,r
SOUTH YARMOUTH, MA 02664
OO 19$&2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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