HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BUARD OF HEALTIi �:
APPI.ICATTON FUR I.ICENSE/PERMTT-2(!17 �
�Pleass complete form and attach ali necessary documents by���;�r 1,�+ �i¢
Failure ta do so wili resuit in the return of your application pac�e3.
ESTABLISHMENT NAME: �v�5�c JS�2 �� • - � �1 S
LOCATiON ADDRESS: 1 oo're �o �i} } 'CEL.#: �J 6 + - (o' - �-13��
MAILING ADDRESS. .rne �
E-MAIL ADDItESS: " c o l fl - ti ca R �
fJWNER NAME;
CORPORATION NA14fE(TF APPLICABLE�: v'1� �.5 �..nX�,,
MANAGER'S NAME: TEL.#; ��3��5
MATLING ADDRESS: SV,,�rv�2 � n .-�.���
Pt?OL CERTIFICATIONS: UJ ��� �Wr > >N c .-�Z 0.�' Gl �t7�'�`CZ C� W e
Tke pool sapervi$or mnst be certifieci as a Pool��D�tar, reqnired by Sbete lsw. Please list the designated ---�"?
Pool C►peratar(s}and attach a copy of the certification to this�rm. �
L 2. 'i � � ��
� n �
Poai aperatars must list a minimum of two empioyees currently cextified in standard First Aid and Community '�- � `�
Cardiopultnanary Resuscitatian(CPR),having one certified loyee on preinises at ali tirnes. Please list the -� �o E
employees belaw and attach copies of their cer�ifications to this�orm.The Health Degartment wiii not aee pAat ;� �-��
yesrs'recards. Yoe must prnvide ae�r copi�and mnintaia a fik at your plauce af basine�s. ;-� o �i��
1. 2. --�1 c� �'s'
3. 4.
FOUD PRaTECTTON MANAGERS-CERTIF�CATTON d��'`��� � O���`'�
Ali food service establishments aze reqtured ta have aY teast full-time employee who is certified as a�no� � �
Protection Manager,as defined'zn the State Sanitary Code for Food Service Establishments, 105 GMR 590.000. ' ' `�
Flease attach copies of c�rtification to this application. TLe H+�Ith Depar�nent will not use past years're�wrda '�
You mast grovide new copi+�and msintsin a file at.your establishment� �
.-,.^ .^�,,`,
�. ��1��c�����f's,Nc� 2. �
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�
PERSON IN CHARGE: �,,;- =
Each food establishment must have at least one Per3on In Charge(PIC)on site during hours of operdtioa.
1. � J� �'PJ� 2. s� .�N�C� �N�1 ��-�.�
�£
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ALLERGEN CEItTIFICATFONS;
All faod seruice establishments are required to have at least one fulI-time emplayee who bas Allergen certification,
as define�3 in the State Sanitary Gode for Faod Service Establishments>105 CMR 590.009(G�3xa). Please att�h
copies of certification to this application. TLe Hsalth Department wi11 mot use paat years'records. Yan maat
provide uew copie.s sed maintain a file at yo�r e�stxbliahmen�
�. �•����c��e+.�ci a.
i�IlvlLICH�ER'iTFICATIONS:
All faod service establishments with 25 seats or more must have at least one emptoyee trained in the Heimlich
Maneuver on the premises at a(1 times. Please list your eit�ployees irained in anti-chokui$procedures below az�l
attach copies of e�nployee cer#ifications to this form. The Hextt6 Department will not ttse psst years'reeards.
You muat provide new copia and m�intnin a Sle at your plaee of business.
i.�h-�,.���G���`�S 2.
3. 4.
RESTAURANF SEATING: T�TAL#_�
OFFICE USE ONLY
LODGIlYG:
LICENSE REQUIRED FEE PEitMIT# LIGENSE REQUIRED FEE PERMIT# L10ENt5E REQiItRED FEE PERhMIT#
'7�B�&B S55 CASIN SSS MOTEL 5110 -�-7�-��-
=(.ODGE SSS '" ' " - _fRA�ILER PARK Ss05 �WHIRLPCX3LNOOI,�tll0ea.�/�'+-�'=�'�/�
FOOD SERYICE:
L[CE1VS£fiE UIRED FEE PEg L ENSE REQUtRED FEE IT# LICENSE�Q t�7[RED FEE PEItMfC#
0-100 SEA 5125 --\� �CONTINENfAL $3S ���8 NON-PROFIT S3U
�Ii1U SEATS 5200 COMMOTi VIC. $60 'WHOLESALE S80
� =RESID.KI7'GHEN SSQ
RETAIL SERVIC�:
LICENSE REQUIRED F'EE PERMIT# LICENSE REQUIRED PE£ PERMIT# LICEN3E RE{�t71REB FEE PERMIT lt
'C50sq 8. S50 >25,Ofm &. 5285 VENDiNG-FOOD S25
TQS,{�sq.R $150 "�"'-" =FROZEN�ESSERT S40 �TOBACCO S1 t0
AIAME CHANGE: ais AMOUNT DUE _ $ �L(,`��?� C,1(�
••*"'PLEASE TURN QVER AND C'OMFLETE OTHER 5lDE OF F'�RM;'•r'
RECEIVED 12I19l2016 12:06PM 5�83628�34 CD�DNIAL H011SE INN
Dec 19 03 12:11 p Custom Cards of Maine 2078649976 p.1
12/i9l2616 20:51AM 5063628834 CQLONIAL HOIJSE INN PAC;E 0Z/91
ADlw�1VlSrl'RA�'1'IO�1
L'nder C7�aptoc i52,Stction 2SC.Sn6�e�tia�6,dte�'uw�oR afYero�aash is rnow�rcd to bofd ix�.:�a.ar�ertew�i
of m�y liaeese ur pe�mai��o apeeate a bnsuse�if a pe�so�.aQ oampaap�doee aac have a Certifa�e oE worir�r'a
CanAensaf�, I�suraaae. THC ATTACB�a STA'[T WqRd�[k'3 CUM�NSA'��O�i �N5U�ANCE-
A�ID,AY�T MIIST$�COMPLE'f'CD AND SCGNLD,G8 , •
C�RT.f�'XN5L3RANCE'ATTACHED t/
OB
WO�E�t'3 CC1AbP.it�1UAVCl'SIGNEU ANI!ATI'ACF�D
ra�ra of YmmoeNth.texea�u!lieas must he peid p�iar ta a�of ycar pe�ui,ts. P�.F,ASE C�CK
APPR4PR�AT.�.Y ff PA�3;
�fE.S TVp
M07��S AND UTRER x.CIDGING�STA�I.[S��NTS
�A►�lr9�ENT OCCtT�'APICYc Forpu�posesoft6e ltrn;�rdo�ofMaet or�-IoD�I u�e,Ik�ocxupa�acy al�al�be
lix�ti6e�to lb�e teeupmtsty aud shori tttak oCcuP�Y.��y�d Custom�rri'�y�sacisted wit3 mo6el artd haMt nse.
7}aaeteyt occupamds mqst i�avo aud bt ab�e�o dt�a�ate tl�at ihey a�siratain.a priaMpal pLu�of rcqidtnoa
d�ewh�er�.Tra�a�art aca�pa�cy e�]1 ge�reber to coatiquons uccupaAoy afm+otrnore't3�an.dra'4�(34}d�yre.�nd,
�agg�egaoa of.na mocre'Otaa niat�Y t'9p)ti�s w�i4 etq'suc Cb7 a�a�JP�-[I�e afa gucst woit ss arcaidoacc o�
d..dling w�it s1�aN auc be c�s�ide�ed t�xaot. O�cupmc�•th���su�bjact so tlie�allection of ltoam Ocwup�cy
�Cci,�e,�det�aad i,u M.G.L.c.64G ar 83Q CMR 6�1G,Ei9 a�eaded,a6a11 g�oecsl�y�e coQsidered�t
POOL3
�OOL�PEl+ID7G:AIl sv+nn�aouaig,wading a�d vrhirlpools wl�ic]�have ban do�od fartT�a seaeaR►must6c i�spaxed
by t�e Ha�th Aeperta��++at a,ox�a q e�irsg. Cos�ct tha ilcalt6 I3e��ent tio�l�cdaie dao t�r�e(31
d4s p�ue't,�ope�iuS; '�eople elo I�107'silow'ed b e'n Ro tht.po01 ar�1in[il��l has bee��
��d�� .
PQOL WATER TESTaTG: Ths w�s�auaf be tcsoed 6oc p�udarnammi,tota]eotiforrn and s�ani lai�c�1t
by a�.9�e ceYlifed.lsb,aad m6aoittai to the Health Dtp�etlt t�u�x C3)dal.$p�o�'to upep�&�4�a�Y
POUL CLQ�R�"1G:�very oucd,00r io gr�uod sw iu�tio�Popl tuust tie dt'sivaed o�cuvered v+�thia acvci�da�rs of
clasidg.
�^oon sERv�G� �
S�ASO�P�I.�'QOD S�RYIC4 UFENI�YG:
AU,food serviae e,s�irli�meiris l�be iu3�ec�d by the�Icaii�Depatta�,�,mt Pripr ts�enit�. Pltaq�ca�t the
H�ekL DcpaAunr.�tt to�ed�te ffie ta�pect�on ttuee(33 days p�{or�co opell��a8-
C,A�?FRING POI.ICX-
Ar�one whu csoecs a�hlda dxe Taw�.a!'Xac�uvat��ust no�fy tbe.Yaemoud�Nea�h�epamonenr bq��ing e�io
�tgnit�td T Pood ServioeA�p lica�on!'omin 721tcru�'s psior t+o't�e cat�ted eve.�ot. Theae•furms c�bt
�a��H��De�hne��4r�iourtfte Towa.'s w�baiz�e at svwu�vareoout�.meeu�uade,r Heelth Dep�t,
FgOT�3�T DS�BERTS: .
Ft�ar.en�deBs�Rs�anu�t 1se tesbed'by a SYe�s c�e�d]ab�for Oo c�i�en.d moal�y d�t+e+�3es,wit1�sarnp�e�esu4ts
suba�itted bo t2ue Healttr Ihpa�ment. P'aiturce to do so w�1��tc�+n�e s��sioa wr revucr�tian of y�aur�
Dessa�t FertniC uotil the�ova oe�s hs�re beea met.
�U7'SmE CA�S: �
(Juls�de cafes(i.a,ovtdoor seating witt�write�/wai�ss�vxce),m�mpt bave p�io�c spp�oval frop't d�e Boa4d a�'�ealth.
OUT.Di)08 COOKING:
auc3oar eooldqg,pre}uxation,o�t dispxay o�aryfaad pxoduct hjr aree��$ood sarice e�abushu�tnt is�ru4ibi�ed.
N�TICE:Peanits rim adaually from Jane�aty 1 tv D�6et 31_17'JSYO�TAt�'�f�B0.�7'Y TO RETlJRN
17�Ct)MPL6T�D RENBW'AI.P,PPLlCATiUN(S7 ANA R8�[1I��FEE(S)BY DF�lb�,2Q�5,.
AT,�.R�NOYA'�'ldt�iS 1Y).ANY F�OD �STABLISN�'sP�l't; MOTII; dR:PUDI.��.e., �A1N'3TNf�, 1VE'W
EQTnP'MENT,E7�C),wi[f5T B�E REP4R'iFA 17D AND A�PROV�D.BY'I�3P�OARD 0�HF.AZ,T� P�OR
-ro co��,rc��sr(tr. �vwr�oxs�tA.�t�r�[ru�a.s� �r
DAT&-�Z�J � I( � 6 SIGi�iA7URB: �°�
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pRIN�NAM�dt In�,�, � �`�S ;r�f-.-f
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Client#: 536450 2COLONIALHO
ACORD,� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
12/19/2016
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 NAMEACT DOWllllg Si O'Neil
Dowling 8�O' Neil Insurance Agency ac"N Ext:508 775-1620 F"x
973 lyannough Rd, PO Box 1990 E-MAi� ,vc,No: 5087781218
ADDRESS: COI@CIOIIlS.00111
Hyannis, MA 02601
INSURER�S)AFFORDING COVERAGE NAIC#
508 775-1620
�NsuReRa:Associated Employers Insurance
INSURED INSURER B:
Perna Consultants,Inc. D/B/A
Colonial House Inn INSURER C:
277 Main Route 6A INSURER D:
INSURER E:
Yarmouth Port, MA 02675
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.
�j� TYPE OF INSURANCE NSR WVD POLICY NUMBER MM/LDDY� MM/DDY� LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISES Ea occurcence $
CLAIMS-MADE �OCCUR MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
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
HIRED AUTOS AUTOS Per accident $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
A WORKERS COMPENSATION WMZ80080035742016A 4/01/2016 04/01/201 X �STATU- OTH-
AND EMPLOYERS'LIABILITY Y�N T IMIT
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $SOO OOO
OFFICER/MEMBER EXCLUDED? � N/A �
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $rJ��,�O�
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO,OOO
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional 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
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
#S182416/M182415 CBD