HomeMy WebLinkAboutApplication and WC�
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{ TOWN OF YARMOi�'17�BOARD OF AEALTH � ; r�e: � � Lt���
; APPLICATION FOR I.ICENSEI�F,RhIIT-2817
'' *Please camplete form and attach all noc�+documeats iry l 1 . �����Y :-;'��
i Faih�e to do so will res�it in the rehut►of yout applicahon _ _ _�_ ___
i _
j' FSTABLTSH1vI�NT NAME: a ss' �v�rz �c��w-� 2/g
i I.00ATION ADDRESS: i?3 i R o�-F� 2 B So�-1-N ,a rz�.o u;t-ti TE�..#� .�'a 8—°J bo-,5'�I 9 9
� MAILII�iG ADDRESS: _
{ E-MAIL ADDitFSS: s.r^r 5 yJ�rz. j,�t�.p rz S Q C�+� C a-s • �Y�.'�'
1 OWI�TERNAME: A�r�►�.a nro � . l...a��z.o+v
� CORPORATION AMEN�,{'�APPLICABLE):
' �ACT'��r�N�" �f'�l0 M O N'P (r� �,/4.1S-Z.6.ti 0
`'( TEL.#•� f3 -'16 O -s�q'�
MAILING ADDRESS•__ S�m.�
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POOL CERTIFTCATIONS:
The pool seperviaor m�t 6e arti6od�u a Pool Opentor,as re9aired 1►p State b�v. Ptease iist tLe deaig�ed
Pool Op�or(s)aud att��cs�'of t6c certificatioa�a t�ia fenn. = v �
l. 2 . D ,n ��
r �
Pool operaWrs mast list a minimum of twa�np�oYees canr�ttY cetiifiod ia�d First Aid and Cominunity � � �
Cardiopulmonary R�t{CPR�,havi�g one catif�d ,_ � at all times. Pl�ase h4t the o � �r
employees below and at�h'oop►es of dieir�to thisa�'1`he�[d��w+��t�p�st � �
yeara'reeorda. Yon mast pravtde new capies snd�taid a�iie at yoar pbce b�aai�eas. �a —� ���
-i v� �'�
1. 2.
3. 4.
FOOD FROTECTtON MANAGERS-CEdi.TIFICATIONS:
Ali foad ssrvice e�ablishments ffi+e required ta hav+e at least�e fiill�emplayee v�rho is ce�tified as a'Faod -
, �-�
Proixtion Msnaga,as defined'm the State Senitary Gode for Food Service Establishnoents,i p5 ChIIt S90.OElQ.
PSease attach copit�of�sxtionto this�on. T��Depsrb�catw�rat ede�tydtss'r�
You maat provjde n�+v capia asd msintsia a i�e at year estab�shme�w b� -��:,f
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PERSON IN CHARGE: A
Each food establist�ent mast l�ave at le,ast a�e Person I�p C�ge(I'IC)on se6e�t�ours of ep�.
��:
1. 2. '`�� �,
ALLERGEN CERTIFICATIONS:
tUl food ae;vice establisbmaus aro requic+ed to have at lea�t,o�e fWl-time e.mpbyee wl�o has Allerge�oertification,
as defi�d in the State Sanitecy Code for Food Saviae Establishmems,145 CMR 590.�09(Gx3xa� Plea�ausch
copies of catifica�i�to this application. The Ha�it6 Departse�t w+�aat�e pa�y�a�ra'reoerda. Yea m�t
provide new oopiea aad mai�taia a Sk at 3�aar esab�hmeat
t. 2,
HEIMLICH CERTIFICAITONS:
All food service e.stablishments wiW 25 seats or more must bave at least o�ee empbyee trained in thes Iidmtich
Man�va on tfie�i�s at all t�nes..Pkase list ycwr �o�s t�ainod in a�i,c�Olciag p�ooal�s+es hebw;aod
�ch copies of m�pMyce�to t1�is fo�m. T�e l��i w�irat a�e pa�t�us aeoar�.
Yoa�ast provide nea copiea sml�lav i fik at yoar place�
1. 2,
3. 4,
RESTAURANT SEATING: TOTAL#
� . �����---�....�.,
�oucuvc:
OFFICE USE ONLY
L��EQIJ�tED SF�E3 PERMff i L[�REQUIRFD jF�� PF;RMP!'# LI�RF.QUIItED F� PERMIT�1
�I.OD(iE S53 _IRATtER PARK 51035 �WH(�RLPOOL��j�0a�.
FOOD SBRYICE:
L[(�ISE FEE PERI�!!!'i� LI(�NSEREI�RRED FEE PERMITN i.ICENS$ Ffi� P'ERMITM
a�oa�si2s _oox�xr�rm�+t S3s xoH-rRRo�° s�o
y�oo sFwrs rmo co�oH vte. s6o _� y�o
usrwn,s�v[cr:
...._x�.�s�o
LICENSE REQ[JlRED FEE LI(:�T?SE REQUIItED FEE PERMTf M LICENSE REQUIRID F� PERM[f M
_j_,<SOaq.R� SSO �Z8 a250Q0 f285 VENDII�Ki-FOOD t23
_�15.900eq.R. 513� �R�1d�T S40 VENDIIK �,../,►`'
�� Sil@ ���.y��..
NAME C$ANGE: SIS AMOU}VT DUE a S I(rO.00
•rt�rPLEA�'[�JRN OVER AND COAQI.STB(YfHfR S1DE OF FORMr"" i
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�
� r ADMINISTRATION
i
Un�Ch�ter 152,Soction?SC,Subsaxion G,d�e Townof Yazmouth is�w ncquired to hold issuance orrenewat
of any lic�e c�pe�mit to opdate a business if a pers�a�co�np�y�es�t have a C�e of Work�'s
! Canpe�ion I�noe: THE AT`TAGHLD STATE WORKER'S GQMPEN3ATIOI�T,IN�RANCE ;
� AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR !
i
�
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CERT.OF INS[7RANCE ATTACHED
OR
WORKER'S COMP.AFFIDAVTT SIGNED AND ATTACHED
II Town of Yarmouth t�xes a�d liens amst be ' ' w rrnevva!or issuance of 'ts: PLEASE CFIECK
P�P� Y�P�
APPROPRIATEi.Y lF PAID: , _ .
YES ,G NO
MUTELS AIYD OTHER LODGING ESTABLISHMENTS
;
TRANBIENT OCCUPANCY: For p�uposes of t�e limiffition�ofMotel or Hotei use,Tr�mt ooc�ncy shali be
limited to the Lempora�y and short teim occupency,ondinarilg s�i cvstomarily associated with�otel anci I�el use.
, Transieat occu�must have and be aWe to danongtra�e tbai they maintsin a�incipat pla�ce of nsicjence
elsewhere.Ttansient occupmx.y shatt generallyrefer to co�inuous occupancy of�mote th�tthirty(30}days,atd
an�e ofuot more than ni�ty(90)days within any si�c(6)month pesiod. Use ofa guesf unit as aresidence a�
dwelli�imit�atl not be�idei+ed tcansient. Oc�t�p�cy ti�t is subjoct w the collection of Room O«;upancy
Excise,as�fiued in M.G.L.a 64G or 830 CMR 64G,as amended,shatl geaerally be caosidered Tt�nsie�rt.
., , �OI.S . . , _ _ .
POOG OPENING:Al�swimmin&wading and which l�ve bee�clo�ed fo�the season must be in�ected
by the Iiealth Dep� � r�,. Ca�►tsctp���Health�i�t tc�se4edrle the��e�a t4ree E3)
!iaYs Pr�'to ora�. :Peapic are NOT allo ta sit in the poai srea u�il pool�+s bed�
u�spected and opeaed.
�OOL WA't'ER TEST'ING: The wster must be tested for pseudomonas,toEa(colifoan a�d sta�ard plate cotmt
try�ceatif�d lab,�d�it�od to fi�e Hea�th D�t three{3?�P�'���Q�Y
POOL CLOSING:Ev�y owdoo�u�B���8 P�1 must be draiacd orcoveaed within s�.wen(�days af
cl�ing.
FOOD SIItV10E
SEASONAL FOOD SERYICE O�'FNING:
Aii faod�ervioe��t be ia�r.�cted b;y fl�e�D�pria��opeaiog: Please�the
Heaidi Dep�t to schedule t�e inspecttoq►t�Oe(3)�sl��'�aP�B•
CATERING POLICY: .
Aayone who cat�ers within tl�e Town of Yarmo�h must notify the Yarmouth Health D�t bY fi�8�
requauo�T Food Service fo�nn T2 I�xs}xior tia the c�terod ev�. Tbeae fom�s can be
obtRit�t at t�e�H�De�ent,or��Town's vwebsite at www.y�� me.us under He�tth U�ent,
Downlo�dable F�ms.
FIt07�N DESSER'TS:
Frar�eai d�ts most be t�sted bya S�te ceatifued lab pa�ior to openiag ae�d monthly thaeafter,with sample re�lts
std�itGod to 8�I�e,sith D�: Failiae ta do so'wiill nesutf in ffic�or nevoc�tio�t of p�r Fmze�
De,4sert Pennit uatil the abave t�ns im�e be�n�t.
OUTSIDE CAF�S:
Outsidoe caf�s(ie.,ow�o�.scating with waitedwaitres.s servi�},must imve prior��1 from the Bnend af Heahh.'
OUTDOOR COOKING:
ch�tdoa�r��am,a�d�ayef�y�vd�o�Ctbya�ail c�r fo�ci.eervioe�art ispr�o�.
NQTICE:Peanits r�mad�atly from J�y 1�D�arnber 31.1TTSY0URP�FSYO�tSIBII�TY TORETURN
THE CObiPLETED RENEWAL APPI.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016.
ALL RENOVATiUNS 1'O ANY FQOD ESTABLISH[ME'Nf, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST BE REPORIED TO PROVED BY THE BOARD OF HEALTH PRIOR
TO CO��'t: RENOVATIONS Y A SITE FLAN.
DATE: � 2-S.. 1 C-, SIGNA - �
PRINTNAME&TPfLE:��ym�.� E - �.�o�.c..zo,v
R�w.(0/12/16
1
DFc. 5. 2016 10;41AM Bri�ar Expre,� Stn: 51�-4?�-0224 N�. 22$5 F, 1/1
,
Ac R,c� GERT1FfCATE OF LIABtLITY INSURANGE °"T�`"'"'°°""""
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THIS CER7IFICATE IS iSBUED AS A MATTER UF INFORMATfON ONLY AN13 GONFERS NO RtOHT6 UPON 7H� CpRTtFICATE HOLOER. TH15
, CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIUELY AMEND, EXTEND OR ALTER THE COVERAGE AFFpRUED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE OOES NOT CON571TUTE A COIVTRACT 6ETWEEN THE ISSUINa INSUREI�(S�, AUTHORIZEO
� REPRE9ENTATIUE OR PRODUGEft.AND THE CERTIFICATE tiOLOER.
' IMPORTANT: If lhe certificale hotder is an ADDITIONAL INSUREO,Ihe policy(ies)must be ehdorsed. If SU6ROGA710N IS WAIVED,su6Ject fo
� lhe terms and condiiiobs of Ihe pollcy,cerialn pollcles may require an endors�menL A slalement on ihls c�nf(icate does naf confer rlghts lo Ihe
caHlTfcata holderin Ileu of such endorsement s.
� PRODVGEft . . .. . . ��Ci .
Cove Risk Servicoa.1.LC �,�E
PO BoX 858z22-8222 EMAI�
Brain4ree.MA 02185 A6DRE$S:
� � INSUflEfl 3 AFFOIiDiNO.COVERAOE. � �NAIC�g
ihsuAeRn: MA ReleA Mercfiants WC Group Inc:
� IN3VAE0 . INSUflERB: �
Bass River oisco�nl Liquo�a,�nc. rwswiertc:
9`st Rle.2B
SOVIh 1�8frtlOVlh,,MA 02664 IkSUflERU:
I INSURER E:
1M3UREf1 F:
; COVERAGES CERTIFICATE NUMBEIt: 0850�s IiEVIS10N NUMBER: 00001
THIS IS TO C�RTIFY THAT TH�POLICIES OF IN3URANCE LISTEO BELOW HAVE BEEN ISSUEO TO THE INSURED NAMEdA80VE FOR THE POLICY PEWOD
INDICATED. N07W{THSTAfVDING ANY REQUIREMENT, 'fERM OR GOND171pN OF ANY CONTRACT OR OTHER DOCUMEM WI7H RESPEC7 TO UVi�CFt THIS
CERTIFICATE MAY BE ISSUEU OR MAY PERTAIN,TNE It�ISUR�4NCE AFFOROED BY THE POUGES OESCRIBED HEREIN tS SUBJECT 70 ALL THE TERMS.
EXCLUSION3 AND COND1110NS OF SUCH POUCIES.IIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CtA1N{S.
�bsR rYPeoplNsupnNC� D s ea POLtC EfF POL P
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COMMERCfALGENERALUAi31UlY .pqB111SES(Ea.00cunence S .
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, POIIC�' j� LOC 5
4UT01�1[7BILELIA9IUTN COMBINEDSi� 'L-LIMY �
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A�� FD . ���ULED 6001LYINJURY(Pg�&Oc�OenQ S .
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. W9RKEfiBGOMPEN9AT16W x WCSTATU- OTM- �
AND EMPLOYEfl3'UABILITY r�N ,Q _ �
ANYPROPRIETORrPARTNER/EXCTUr+VE ELEACWACGOFM S �OO,OOO
AOFFlCER/MEINBEftEYCLUDE09 � NfA
IManOelorylnNM) p1400Q501077117 !01/2017 !p1l2p1g �•�aSEhSE-EAEMPLOY s 100,000
u y��d�.���e«
OG9CRIPTIONOFOP�FtATI�NS6oiow E.LDISEASE-POLICYUNUT �S �JOO,OOO
OEBCR�PTION 9F OPERATIDNBI IOCAT1�18/V9{ICL�B(ANach ACORD 107,Add�Uona�Rcmarl�fi t,dudura K md'a spaoe�s reqol.ed)
Fax 508-76034i2 508-760-5A04
CERTIFICATE HOLDER CANCEI.LATION
Tawn of Yarmouih
ATTN:Heallh DepaAment sHoULb ANVOF7HE A80VE DESCRIBED POLIGIES BE GANGELLED BEFORE
1145 Rle 2$ THB E%PIRAT(DN DATE THEREUF. NOTICE WILL BE DELIVEREO IN
SoUlh Y3rmoulh.N{A U2884 ACCOAOANCE WITH THE POLICY PqOVI&IONS.
. AUTFpqF2EOR�RESENTATNE � .
/�`��/�-^�i�'{�'"v v/
C�11988-2090 AGARD CORPORATIOW. All dghts reserved.
ACORD 25(2610l05) The ACORO name and Jogo are registered marks ot ACORD
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� � �!'Ct�1�At�k,1?,f M�C��.
� ' `oflndu,r�trialA�cide�rt.s
� O�'ice ojlRv�es�ig�rtions
' i Co�gress,S'�ree�Sr�e IAQ
` Bosto�c,A�4 02I1�2017.
, www.�gov/dia
Workers'Compeesatioa Iasarxace Ai�idavi� Geaersl Ba�iaesses �
A��nt Information P�e Pr�t Le�'blv
$usinesslOtganiza�ion Name: �A S:s�t r���- � �s r o wn.s�- L.i bZ w�n,� 'T';�,,e ,
Address: �i`31 �o w-�-� 2 r3
City/StatelZip:So�..--�-� ���n�.o�-h� � Phane#: �o& - '7b 0 -���q
,
Are yowr sn employ�?Check�e appropriate bozs Bas�s TY�(�9�3�
1.,� I am a�ployer with 7 employees(fult and/ 5. �Retail
or part time)•• 6. []R ' g Establisltme�tt,
2.� I am a sc►le prnpri�or or partneaship�d have ao,
, '7: (]0ffic;e aad/ar Saies{incl.reat e��,d�c.)
employees working for me in snY cap�c�tY-
[No warkeas'comp.insiu�nce required] 8. ❑Non-pro�fit
3.❑ We are a corporatioa and its officers have exercised 9. ❑E�te��
� their right of exemption per c. 1 S2,§I(4�arnd we have I O.Q M�ufac�uing
na�nployee,s.(No worke�s'cornp.insurance requiredl* 11.Q Health C,are
4.❑ We are a non-grofit organization,staffed by vohmtse�s�,
' with no employees.[No worke�s'comp.insurance req.] 12.�Chher
•My ap�lix�Wat diecks boai t�t awst alao Su out We saxian bdow�aw�tt�.vrxioas'oo�aa t�oli�y mfocmrioe-
:s���affiaas henAe e�oe�d�,but tbe oo�o�ation�e�er emp�loyees.a wotioas'oom�oa Pdicy is ieqtmed aai�h ae .
oc�tion s�hould t�Ck booc#L
I aAe an�tArrat itsPrnvid�ie8�ke�'eo��ra�f��1'� Btlaw ls t�t pn�fey liee,��
Insurance Company Name: _ _
Insurer's Adc�s:
City/S�e/Zip:
Foficy#or Self-ins.Lic.# ���.
Atbch�t oopy of tl�e workera'oompeasatt�t po�cy d+e�arstio�p�ge(siawieg t�t p�cy s�mbar a,d e�p�itt�nt tbttt�.
Failune w svcune covera�e as r+equired unc�Section 25A of MGL a 152 can lead to ffie�of crimmal pa�alties of a
fine up m S 1,50(!00 andJor one-Year u�prisanmeat,as v�ll as civil peuatties in tt�foim of a S"PUP�VORK C►RDER s�d a Sne
of up w 5250.IX!a day against ffie vialator. Be advised that a copy of t�is st�►ent may be forwarded ta the C}ffice of
Investigatiac�s of the DIA for insarance covaage veriScation.
I do ,.►�t�rcp�e`so+�d olp�ay�t��'on��a�vr�,s are�t�
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�#: .��8 - �760 - �� 99
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�lj9ciat rra+e oArly. l�n�t wri�r�tl�s ar���C ca�a�d b�'c�p or�c o�ci�
City or Towa• P�rmit/I�se#
�saebtg Authority(circk ose):
1.Board of H� 2.B�eildi�g Depsrta�e�t 3.,City/Town Cl�k 4.Licx��ng Bosrd S�.Sdecta�ea's Olfiee
b.O�er "- ,r
Coatact Person• p���
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