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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 I6.2016. Failure to do so will result in the retum of your applicahon packet. ESTABLISHMENT NAME: vf.r ta C.� $a � � LOCATION ADDRESS: (3 3� �' a$,� . �Q,�mot.l �1+M A �blc�TEL.#: S� "'3`I$'a�� MAILING ADDRESS: ,M� ' E-MAIL ADDRESS: i Q, I e.. (�1 v�21 W q C O rhC Gt S'�'•+�Q. t O WNER NAME:-'�G1S 0►'� i S C-C CORPORATION NAME IF APPLICABLE): MANAGER'S NAME: �P.r � �pn L.e►'h D� TEL.#: S G� MAILING ADDRESS: S A nnit, POOL CERTIFICATIONS: The pool supervisor must be certif ed as a Pool Operator,as required by State law. Please list the designat i Pool Operator(s)and attach a copy of the certification to this form. i i. N�t� a. T o �"'� --- rn �-n �.-:;,� Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � v t `" Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all rimes. Please list the � � ;�� employees below and attach copies of their certifications to this form.The Health Department will not use past p �,. �:} years'records. You must provide new copies and maintain a file at your place of business. r� ' o �-�,�> � �� .I -� O) �? � 1. 2. 3. 4. FOOD PRQTECTION MANAGERS-CERTIFICATIONS: ;-� All food service establishments are required to have at lea5t one full-time employee who is certified as a Food � -�'":'� Protection Manager,as defined in the State Sanitary Code f�r Food Service Establishxnents, 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. _ i. ��r �2G� �U:rtd 2. �� C� �GZ( �'v1.Q.� � ..; � PERSON TN C ARGE: "" -3 : � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � I � ,1 � t�,�, ,�.." �� 1. Z-�1 �'n �'ei�"�'1 t�rj 2.1��--�1 5 cJ�' 1� �'r 1 �(� I V✓� � � � -__- . F+...�'_�. � ALLERGEN CERTIFICATIONS: �•��`r� M U SU fe... All food service establishxnents 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 61e at your establishment. �. Z� r i 1 t��1 L�.�-��S 2. �'�� S Sa I+or r-r i,n.q �}-�p n I 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 rimes. 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. i. ��iCa ��'�i� 2_ MPI�SSA �-}a��i�q ��+ 3. r iSci i1A � � 4. en; ,. RESTAURANT SEATING: TOTAL# '� t � ' OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMCI'# LICENSE REQUIRED FEE PERMIT# B&B S55 _CABIN S55 MOTEL $I10 1NN S55 CAMP $55 _SWIMMING POOL$110ea. _I.ODGE $55 =TRAILER PARK $]OS WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQ UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#' 0-I00 SEA1'S 5125 CONTINENTAL $35 _NON-PROFIT $30 =>100 SEATS $200�y �COMMON V1C. S60 ��37 _W}IOLESALE S80 —RESID.KITCHEN $80 RETAIL SERVICE: LtCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# <50 sq.ft. S50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. 5150 _FROZEN DESSERT $40 =TOBACCO �]10 NAME CHANGE: �15 AMOUNT DUE _;��,�,l`� ' *'"**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•**** '�� 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 '. OR 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 APPROPRIATELY IF PAID: YES NO MOTEL3 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 piace 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 the Health Department prior to opening. Contact the Health Departrnent to schedule the inspection three(3) days prior to opening.PLEASE NOT'E: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 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 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 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 AN APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEM NT. RENOVATIONS MAY Q A . � DATE: � oZ 0 �V SIGNATURE: PRINT NAME&TITLE: �(�1 C� S( S C C)e � C� YhG nQ�; Rev.10/12/t6 � The Commonwealth of Massachusetts , Department of Industrial Accidents O�ce of Investigations � 1 Congress Street,Suite 100 Boston,MA 02�14-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv Business/Organization Name: I��r�a ��S� H�u� � �t- Address: �� a� �. Gl��.t -I��M/-� �a Ph ne#: 5��- 3q 8-01 I �'a. City/State/Zip: � Are you an employer?Check the appropriate boa: Business Type(required): l.�I am a employer with tA � employees(full and/ 5• ❑ Retail or part-time).* � 6. [v]'kestaurant7Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. �I�To 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 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•0 4ther •Any applicant that checks box#1 must also fill out the secdon 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 employees Below is the policy tnformation. Insurance Company Name: :M� ��t� � �.•'' �a�}S � C }�U t7 �Yl C • Insurer's Address: �`�- u Q X $ 5 � ��"� ��a a"a City/State/Zip: �'�Q 1 r1��-� � �t �c�1 �S Policy#or Self-ins.Lic.# o��o 0 5 0 3 a aa a i � 5 Expiration Date: o � �� Attach a copy of the workers'compensation policy declaration page(showing the policy number and eapiration 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,u ains and penalties ofperjury that the information provided ab ve is t ue and correct. Si a � Date: f � �2 � �� Phor,�,e#• �� ^�1��" Official use only. Do not write in thu 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.govldia , �DATE�MM/DD/YYYY) . Acd� CERTIFICATE OF LIABILITY, INSURANCE �� „i2,i2o�s THIS CERTIFICATE IS 15SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THfS � 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 ISSUINGI 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 INSUREq provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and canditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Ifeu of such endorsement(s). ' reoouceR N,°4ME�T Heather Pearce ' Mark SylviaJnsurance Agency,LLC vHONe FAX 404 Main Street �• 508 957-2125 �vc Ho: 508 957-2781 E-MAR AooaEss:kristine marks Iviainsurance.com �� CBII(BfVIIIB,MAOZC3Z � � INSURERS AFFORDINGCQVERAGE � I - NAIC# iNsuReR n:MA Retail Merchants WC Group INSURED � INSURER B: � � .__ Riverway Lobster House,Inc. iNsuReRc: ' 1338 Rt 28 South Yarmouth,MA 02664 ir+suRen o: � . INSURERE: � ' � � � INSURER F: � COVERAGES CERTIFICATE NUMBER: REVISION N,UMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABpVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDWG ANY REQUIREMENT, TERM-0R CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES 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 OP INSURANCE� ADD SUBR . pOLICY NUMBER � MM DD/YEYYY MM%DDY�Y � LIMITS LTR COMMERCIALGENERALLIABILITY EACHACCURRENCE $ _ DAMA 'ORENT_D CLAIMS-MADE �OCCUR PR MISES Ea bccurrence $ . �� . . � MED EXP(My pne person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATELIMITAPPLIESPER; GENERALAGGREGATE $ POLICY❑PR� �LOC PRODUCTS-CQMP/OP AGG $ JECT . � . - . � ,. �$ . - OTHER: � � � . . �AUTOMOBILELIABILITY � � . I . Ea aBcdEeDtSINGLE LtMIT $ . � ANY AUTO BODILY INJURY(Per person) $ . . �. , OWNED SCHEDULED BODILY INJURY(Per accident) S ; AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident _. $ UMBRELLA LIAB -OCCUR � � EACH OCCURRENCE �� $ , EXCESS LIAB . CLAIMS-MADE � � AGGREGATE � $ . �� DED RETENTION$- - � � � $ . F: q wottKEttscon�aENsdrioN . 014005032222116 01/01/2017 01/01/2018 STATUTE. ERH � . ANDEMPLOYERS'LIABILITY . . . ANYPROPRIETORIPARTNER/EXECUTIVE Y�N N�A E.L.EACH ACCfDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED7 �N � (MandatoryinNHJ E.L.DISEASE-EAEMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OP OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space�is requlretl) � � '. ' Food&Beverage Concession Stand Location:670 Ocean Street,Hyannis,MA 02601 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 SHOULD ANY�F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Riverwa Lobster House THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ' Y ACCORDANCE WITH THE POUCY PROVISIONS. 1338 Rte 28 ' ' South Yarmouth,MA 02664 . AUTHORRED REPRESENTATIVE � � � �' � . '. '��{��r'1,=�:.._„� . . , . �?��f�� ... _ .- a 1988-2015 ACORD CORRORATION. All rights resecved. , ACORD.25(2016/03) The ACORD name and logo are registered marks of ACORD