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Home My WebLink AboutApplication and WC a TOWN OF YARMOUTH BOARD OF HEALTFI �� 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 return of your applicahon pac et. ESTABLISHMENT NAME: (� • LOCATION ADDRESS: ��3 Cp TEL.#: � MAILING ADDRESS: r1 � ' E-MAII,ADDRESS: OWNER NAME: �� CORPORATION NAME(IF APPLIC E : I MANAGER'S N �� C� T'EL.#. • L� � (�� MAILING ADDRESS: �Y v POOL CERTIFICATIONS: � T6e pool supervisor must be certified as a Poot Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. �� 1. tn��_. 2. � �< � Pool operators must list a minimum of two employees cunently certified in standard First Aid and Community �' Cazdiopulmonary 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. Yoa must provide uew copies and maintain a file at your place of business. s-�q' � - .t�.. : .,�� 1. 2. �.��,�.,a�`, 3. 4. �.._„T.._.._urm...._r_��v FOOD PROTECTTON 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 fbr Food Service Establishments, 105 CMR 590.000. . Please attach copies of certification to tlus application. The Health Department will not use past years'records. ; ' —' You mus�ide new copies and maintain a file at your establishment. � 1` / �'�� 2. � 0 rn PERSON IN CHARGE: Each food establishment must have at le t one Person In Charge(PIC)on si ' g hours of opera6on. ' i. v � ��ri � ALLERGEN CERTIF'ICATIONS: 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 file at your establishment. 1. ��3��r-a4�`TZ�f�\ 2. . r HEIIvILICH 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-chokuig procedures below and attach copies of employee certifications to this farm. The Health Department will not use.past years'cecords. Yo must provide new copies and maintain a file at your place of business. � 1. _,�, 2. �it�i�� 3. 4. � RESTAURANT SEATING: TOTAL �� OF USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT# B&B S55 CABIN S55 MOTEL $110 —ID7N $55 CAMP $55 _SWIMMING POOL S1 IOea =[.ODGE $55 TRAILERPARK 5105 _WHIRLPOOL S110ea. FOOD SERVICE: LICENSE REQ UIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT# LICENSE REpUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENT,AL $35 NON-PRO�IT E30 �>100 SEATS azoo ��3 �COMMON VIC. S60 ��f f� =IVHOLESALE $80 —RESID.KTCCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# <50 sq.ft. S50 >25,000sq ft. 5285 VENDING-FOOD S25 =QS,OOOsq.R EISO =FROZENDESSERT S40 TOBACCO 5110 NAME CAANGE: $15 AMOITNT DUE _ � ' .t�3', **•**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*••;* ��, (�� 1 r ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or pemvt 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 pemuts. PLEASE CHECK APPROPRIATELY IF PAID: ! / YES V 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 terxn 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 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 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 reqiured Temporary Food Service Application form 72 hours prior to the catered event. 'I'hese forms can be obtamed at the Health Department,or from the Town's website at www�armouth.ma.us under Health Deparhnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified 1ab 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 Heatth OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establistunent is prohibited. NOTICE:Pernuts run annually from January 1 to December 31. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISH , MOTEL QR POOL (i.e., .PAINTING,NEW . . EQUIPMENT,ETC.),MUST BE REPORTED TO AND P OVED BY Tf�BOARD OF HEALTH PRIOR TO CONIl�IEN E NT. RENOVATIONS MAY SI L . DATE: �Z �CP � SIGNATURE: PRINT NAME&TTTLE: i'� p� � x�.ionvte ��i'1'Yiv� � ✓m C�.�h/��. ; � � � The Commonwealth of Massachusetts Departntent of Industrial Accidents Offue of Investigations ' 1 Congress Stree�Suite 100 Boston,MA 02114-2017. www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Apalicant Information Please Print Le�iblv Business/Organization Name: �� -� �CQ--Ym��.��1n c�r� � Address: ��3 �� ..e� City/State/Zip:��✓�Y1.c�1,5�1'��c�/`�- Phone#: ��' ��- �l -�`'1 (��- � Are you an employer?Check the appropriate boz: Business Type(reqnired): 1.❑ I am a employer with employees(full and/ 5 ❑ Retail or part-time).* 6�] Resta.urantBar/Eating Establishment 2.❑ I am a sole proprietor or pazMership and have no �, � Office andlor 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 have 10.Q 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 'Aay applicaut that checks box#1 must also fill out the section below showing thea workers'cwmpensation policy information. •*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is requued and such an organization should check box#1. I am an employer that�s providing workers'compensation insurance for my emp[oyees Below is the policy information. Insurance Company Name: �(�-�1��I� �� C- �� Insurer's Address: City/State/Zip: ��`�tY��1�'t-�-� -Y1'1�t 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 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 D for insurance coverage verification. I do hereby c ' nde the ai s nd penalties ofperjury that the information provlded above is true and correct. Si ature• Date• �Z �� Ph ne#: �� 3�Z Official use only. Do not w�ite in th�s area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Hea1tL 2.Building Department 3.City/Towu Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia �-�-� 1696COR-01 RNE ACOR�F DATE(MMIDDIYYYY) �,.,,- CERTIFICATE OF LIABILITY INSURANCE 11/15/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATNELY 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditlons of the policy,certain policies may require an endorsement. A statement on this certiflcate does not confer ri hts to the certificate holder in lieu of such endorsement s. PRODUCER CONTACT R ers&Gray Insurance Agency,Inc. PHONE 43�Rte 134 lac.No,e��: pvc,No�:(877)816-2156 South Dennis,MA o2660 App' •mail@rogersgray.com INSURER S AFFORDING COVERAGE NAIC# iNsuReRn:Arbella Protection Insurance Com an Inc. 47360 �r,suReo �NsuReR s:MA Retail Merchants WC Grou Inc. 1696 Corp dba Old Yarmouth Inn iNsuReR c: 223 Main St. iNsuReR�: Yarmouthport,MA 02675 . 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TypE OP INSURANCE ADDL SUBR pOLICY NUMBER POLICY EFF POLICY EXP ��MRS . A X COMMERCIAL GENERAL LIABIUTY � EACH OCCURRENCE $ �,OOO�OOO CLAIMS-MADE �OCCUR 8500053847 12131/2016 12/31/2017 pREMGETORENTEDn �QQ�QQQ MED EXP An one rson $,�� PERSONAL&ADVINJURY �,OOO,OOO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY�jE� � LOC PRODUCTS-COMP/OP AGCa 2�000,000 OTHER: � AUTOMOBILE LWBILITY COMBINEO SINGLE LIMIT $ ANYAUTO BODILYINJURY Per erson $ OWNED SCHEDULED � � AUTOS ONLY AUTOS BODILY INJURY Per accideM $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LWB OCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE $ DED RETENTION$ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY 014005032709116 01/01/2017 01/01/2018 TAT TE ER 500,000 OFFICEWMEMBE�XCLUDED ECUTIVE Y� N�A E.L.EACH ACCIDENT rjOO OOO (Mandatory in NH) E.L.DISEASE-EA EMPLOYE ' If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY IIMIT q Liquor Liability 8500053847 12131@016 12/31/2017 Each Occurence 1,000,000 A Liquor Liability 8500053847 12/31/2016 12/31/201T Aggregrate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 107,AddiGonal Remarks Sehedule,may be attached H more apace ia requlred) CERTIFICATE HOLDER CANCELLATION SHOUID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yartnouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Main Street 7146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE �� -_ ACORD 25(2016103) OO 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD