HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSEt�'ERMIT-2017
' *Please completc farm and attach all necestsat�+documents by Dact+nber I 1016.
Failwe to da so will result in tl�t�t�an of your applicati�pa et
ESTABLISFA�V'P NAME: , 1 1 ("�
LOCAITON ADDRESS: TEL_#:
MAiLING ADDRESS: P�l. D
, E-MAIL ADDRESS:� � e
OWNER NAME:
. CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: �AY�(\e� TEL.#:� �_
a�nvG AnDxESS: �� '71 l O 1 � � �
� �
POOL CERTIFTCATTONS: � c+f (�
The pool snperviaor�ust bc certi6al as a Pool Operator,�reqnired by Sta�e la�r. Please list th,e designated = � m
Poot Operatar(s)and attach a eopy of the ceitification w this form O
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1. 2_ -mv �' f1 i
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Pool opeiatois mu4t list a minimum of twro�ployces curreafly ce�tified in standard First Aid and Community
C.ffidiopuimonsry R�itarion(CPR),having o�cerhfied employce on p�remis�aR all times. Please list the
empioYees beMw and attach copies of th�eir�oas to this form.Tbe Ha�Depart�eat w�uet�t p�t .
ptus'reeards. Yo�m�at previde�esv eopies�)naHttain a�e at yoer plate ef b�.
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1. 2. ... �
3. 4. � ;....�
FOUD 1'ROTECTION MANAGERS-CERTIFICATIONS: �
All food service estabtishmesrts are required to have at least one full-time�ployee who is certified as a Food
Protection Maoager,as defined in ibe State Sanitary Code for Food Seivice Establis�is,105 Ch+IK 590.00Q. � �,,
Pl�se attach copies of oertific�tion to this applicaiion_ The Aestt6 Ikpart�eet will sot�e p�t yesrs'r+aorris. �- � �
Yso muat previde new cepies ud�iataiH st Sle�t yoar eatabiisL�est .�,
1. 2. , 7
PERSON IN CHARGE:
F.�h food estabtishment must have at least one Person In Charge(PIC)on site during�urs of operation.
1. 2.
AII.ERGEN CERTIFiCATTONS:
All food sexvioe e�ablishments ar�ieqwred to have ad least one full-time e.mployce wha has Allerge�o,eetification,
as defined in the State Saoitaty Code for Food Service F.stablishmemts,105 CMR 590.009(G�3xa).Pleax attach
cogies of ceatification to this appiication. 17ie Hadt�Depatta�eat wilt�t u�paat yeara'reeords. Yon muat
provide�e�r cgpias aad�txi�x Sle at yonr esisb�L�ent
1. 2. '
HEIMLICH CERTIFICATiONS:
All food service establishments with 25 seats or more must have at ieast one empioyee trai�in the Heimlich
Maneuver on ffie p�eemises at all tunes. Please list yo��npIopees tcained in anti-choking procediues below and
att�h copies of cm�oyee certificxRions�a tl�fotm_ 1're�ak4 Deryrdreat�riH eot ase pmt ya��s'rewrda.
Yos�agt previde�v cop�es and maiatain a�st yonr pvce of bsaineas.
1. 2. .
3. 4,
RESTAURANT SEATII�IG: TOTAL#
�
Loncnve_
OFFICE USE ONLY
LICENSE REQUIRED FEE PERA�llT dl L[CENSE REQU[RED FE£ PIItM1T� LICENSE REQUIRFD EEE PERMIT A
�B S53 CABIN S55 MO'I8L ;110
�� S53 CA1NP S55 _SWII�Q�IG POOI.S110w.
�1-QDGE TSS _—`IRAILERPARK SI05 V✓f�RLY00I. SllOea.
F�OOD SERVICB•
..�CENSE FEE ERMtT# LICENSEREQUIRED FEE PERMII'# LtCENSE FF.E PF1tMIT#
aioosF�r�s ID siu ��jg _coxrn�n�ru. s3s xox-rx��D sso
>100 SEA7'S 5200 COMMON VIC. S60 WIIOLESAGE S80
ItEIAII.SERV[CE: —RESm.K111�N SSD
LICENSE REQUIRFD fEE PERMIT/ LIC�NSE REQUfRED FEE PERMiI'!t LICENSE REQUIRCsD FEE Pt3iM1'P�
�� S50 >ZS,ppp ft. y'2g5 YENDING-FOOD S25
=QS, syR 5150 '�AOZEN�ESSE1tT Sd0 � 1'OBACCO SI10
�c�+�: s�s �tourrr DUE = s �G 6•00
am:PLEASE TURN OVER AlYD COMPI.ETE OTHF.R SIDE QF F�ORM**•ri
,�joF�F—�S-�o6Q�—OZ
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ADMINISTRATION
Under Chagter 152,Section 25C,Sabsection 6,the Town of Yarmouth is now required ta hold i�uance or renewal
of any license or permit to operate a business if a person or company dces not have a Certific�te of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANGE
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 prio o renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGII►IG ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shail be
limited to the temporary and short term occugancy,ordinarily and customarily associat�ed with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain a principat glace of�esidence
elsewhere.Transient ocxupancy shall generally referto continuous oceugancy ofnot mare thanthirty(30)aays,a�d
an aggregate of not more t�n ninety(90)days within any six(�manth period. Use of a guest unit as a residence or
dwelling unit sha(I not be considered ttansient. Occupancy that is subject to the collection of Room Occupancy
F.�ceise,ss defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be conside.red Transient
POOLS
POUL OPENING:All swimming,wading and whiripools which have bcen closed far ibe�ason mt�st be inspectsd
by the Health Department�nior to opening. Contact the Health Depacunent to sc�edale tLe u�n three(3)
da��o�PLEASE NOTE:P�ple are NOT atlovved ta sit in the pcwl area natil pool has been �
POOL WATER TFSTING: The water must be test�d for pseudomonas,totat coliform ancl standar�plate oount
by��a�certified lab,and submitted ta the Health Dep�tme�t th�(3)days Pn�to openi�,a�d quarterly
POOL CI.OSING:Every out+door in gro►md swimming pool must be dtained or coveted within sev�{�days of
closing.
FQUD SERVICE
SF.�ISQNAL FOOD SERVICE OPENING:
All food service es4ablishments must be inspected by the Heatth Department prior to opeaieg. Ptease�mact the '
Health D�ent to�hedule the inspe�tian three(3}days prior to openuog.
CATERING POLICY•
Anyone who caters within the Town of Yaimouth must notify i�Yarmouth Heslth Departrnent by filing the
���T�H��Food S�rviee Agpiieation form 72 haucs priar to the c�tezecl ev�t The�e forms ean be
D�parhnent,or from the Town's websitc at www_yatmauth_ma.us.under A�ith Depart�t,
Downloadable Foims.
FROZEN DESSERTS:
Fro�en des�ts must be tested by a State certified lab prior to opening and monthiy th�r,with�mple results
submitted to Uie I�eaith Department Failure to do so will rest�lt m the�,�+ci�m�revocati�of qaa�r Frn�
Dess�t Peimit�mtil the abave terms have b�n met
OUTSIDE CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitces.s s�xvice),mvst have prior approvat from the Boazd ofHealth.
OUTDOOR COOKING:
Outdoor cooking,greparaiion,or disp2ay of any food product by a retail or food service es�ablishment is prohibited.
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NOTICE:Permits nui annualty frnm January 1 to Decembea3l. IT IS YOUR RESY()NSIBII.TTY TO REiURN
. THE COMPLE'TED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2U16. �
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,EfC_),MUST BE REPORTED TO AND PROVED BY TT�BOARD OF TH PRIOR �
TO COA�IlI�IENCEMENf_ RENOVATIONS MAY RE A STTE PLAN.
` DATE: t���— ,� SIGNAT(JRE: "'_'
PRINT NAME 8c TtTt, �5
�.imw�6 �
�
a�� CERTIFICATE OF LIABILtTY INSURANCE °"'�`�"'
,�,
THIS CERTIFlCATE I.S ISSUED AS A YATTER OF INFORMATION ONLY AND COMFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER.THIS
CERT'IRCATE DOES NOT AFFlRMATNELY �t NEGATIVELY AMEtiD, EXTEND OR ALTER THE COVERAGE AFFOR�D BY THE POUCIES
BELOW. THIS CER77FlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEAI TFIE ISSUNiG INSURER(S� AUTHORRED
REPRESENTATIVE OR PRODUCER,AND THE CER'tiFlCATE HOLDER.
IMPORTAN'f: H fhe certificate holder is�ADDI710NAL INSURED,tl�e policy(ies)must be l�ndorsed. fi SUBROGATlON IS W/UVED,subject to
tl�e terms and conditions of the PulicY,certain policies may require an endorsernerK. A statement or►this�e does not confer rigMs to ffie
certiHcate hdder in�eu af such endorsement(s).
P� HART INSURANCE AGENCY,WC. w�: E�k O'Co�nor
243 MAIN STREET P� 508-755-7326 x205 ��=508-759-7366
PO BOX 700 �
n�:
BUZZARDS BAY,MA 025320700 ��� �#
n�sur�Ra, TRAVELERS INDEMNiTY CO OF CT 25682
x+sur�u Putters Paradise Mini Goif ��R B:
PO Box 48
Hyannisport,MA 02647 �����
NSIIF�R D:
NI,SY/F�R E-
NIStNER F:
COVERAGES CERI7FICATE NtJMBER: REV�ION NUMBER:
THIS IS TO CERTiFY'TNAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A�VE FOR THE POLICY PERIOD
INDIGATED. NOTWITFISTANDING ANY RE(�UIREMEMT,TERM OR CONDFf10N OF ANY CONTRACT OR OTHER DOClMAENT WffH RESPECT Td WHICH THIS
CERTIFICATE NWY BE ISSUED OR MRY PERTAMI,TNE 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 PAtD CLAIMS.
LT�R TYPE OF W,SINtkICE ADDL SUBN �Y M�BER POIJCY EFF POLICY OCP �S
G�V��'m EACH OCCURRENCE $
C�IMERCIAL GENERAL IJABIL�IV DAMAGE TO RENTED
PREMFSES acarrence i
CLAIMS-MADE �OCCUR MED EXP f�Y�P�) S
PERSONAL S ADV IWURY E
GENERALAGGREGATE E
GEML AGGREGATE LJMT APPLIES PBi: . PR0�41CTS-COMP/�AG6 �S
. POLICY �a LOC � . � . f .
�pNpgpF��pg��y COMBINED SII�LE LIAAiT
Ea
ANY AUTO � BOD�Y MIJURY(P�person) s �.
UT�D�� � q�� . .�.. .� . . . . � . t �� E . . . .
��Y INJURY�PcY
HIRED AUTOS ���ED PROPERTY DAMAGE _
. : AUTOS � � . � . � Per'acciderat
i
g
UI�ELL.A LU16 �� � .. . .� EACH OCCURRENCE ;
EXCESS LY18 � CLAINkS-MADE � � � . � AGGREGATE ; .
DED� RETENTION � � g
A ��o��m IEU62676X333 01/01/2017 01/01/2018 WcsraTu- on+
YIN
^Nv�w�ro�rwn'�Ew�x�cuTwE 01/01/2t}f6 01/01/2017 ��accn�Fn' S 500,000
OFFICER/MEkBER IXCIUDED? � N!A
l�au«r tn►u+) e.�.o�s�as�-En a��ov� S 500,000
Ifyes descn'be under
DESCRIPTIOtd OF OPERATIONS below E.L.OISEASE-POUCY LOrHT S �.0�
�IION#OPBtAi1WlS f L.00A71diS J YBiCL.Q(/lt�eh A�D t01,A�Raerics Sepe�de,H more spaee is eequtad)
CERTtFICATE HOLDER CANCELLATION
Fax#:(508)398-0836
SHOULD ANY OF 7tIE ABOYE pESC1�Bm pOLJqES BE CAHCELLED BEWRE
TOWN OF YARAAOUTH 7HE ExPIRAT1oN DATE 7HEREOF, No710E Mfltt 6E DEuvERED IN
LICENSING OFFICE ACCORDANCE wmi THE POUCY pRovlStoNS.
1146 MAIN STREET
S YARMOUTH,MA 02673 ���5���
��.���✓ �`
�1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and bgo are registered marks of ACORD
� Tke Co�nn�nxwealtli of�Iassachusetts
Deparanent of Indu�r�l Accid��
O,�'tce of IRvestigQtiot�s
' I Congress Stnee�Stute 14l!
Boston,MA 02II,F2017.
www.rx�ss.gov/dia
Workers' Compensntion Insnragce Af�davit: Genernl Bosinesses
App�iC8IIt IllfOi'IHStiOII Please Print Le�ibiv
Business/Organization Name: s �
Address:
City/State/Zip: m' Phone#:
Are yo�n employer?Check t�aPPmFriste iwz: Basise�'I�'Pe(re�laind):
1.��I am a e�ploy�with�_employces(full and/ 5. ❑Re�ail
or part-time).'� 6. ❑R ' g Establishme.nt
Z-❑ I am a sole proprietor or�rtneiship and have no 7. ❑Oi�ce andJor Sales(incl.reat estate,auta,etc.)
emplayees working for me in any capacity.
[No worke.rs'comp.insurance requir�d] 8. ❑Non-profit
3.❑ We are a carporation and its office,rs have eacerciseci 9. ❑Enteitainment
their rig�t of exemption per a 252,§1(4�and we�ire 1�.❑���g
no e�qsloye�s.[No workers'comp.insurance required]*
4.❑ We aze a uon-pmfit organiTation,staffed by votvntceas, 2 L�H Care �
with no employces.[No workers'comp.insurance rEq.] 12.L�(�'
se4ny applicant t�at checks box�1�alao fiD o�the�below shovving thea w�odoas'oo�iun Policy infacm�n.
•sIf the oo�par�e otfiaeas ha+re e�the�ives,�die carpa[�a has otha euq�loyees,a wo�eas' ' paticy it n�niced�s�h ffi
�an shouid checic bmc#1.
I aire mr en�player that is prov�iing weo 'on�on arsuraRt�e for my u�rployre� B�tow is dlrr pnl�cy l�f�on.
Insutance Company Name: � {�.�ZS
Insurer's A�dress:_ � D �(j�[.____���`i'')�j��
CitylSt�telZip: \�5 b �P 'r ��
Policy#or Self-ins.Lic.#___ J� T(� J� , � �
(� � � a � �� �� 1-�- 17.�.
Attach a copy of the�rorgers'compeasxtion poliry dedarati�Page(showiag the poliry a�ber aad c=pintioa date�.
Failur�to�re caverage as req�ured under Section 25A of MGL c_ 152 can Ie�to d�e impasiti�of cximir�l penatties of a
f ne up to$1,500 00 andlor one-year im�isonme,nt,as well as civil pe.nalties in�e fornt of a STOP WORK ORDER and a fine
of up to 5250.OU a day ag�st the viol�. Be advis�ad thst a c�py of this s�t may be farwarded to t}�Office of
Investigatian�s of the DIA for iasurance cove,rage verification.
I do b�by ' , the ' ofperjr�ry lkat tJl�e iAfone�oa provided above is tr�e med cnrred
i � �p
O,f,�ciat use r�lj. lJ�o not write in turis area,to be con�ut hy cify or towh o,�Ciat
Ciip or To�vn: Permi�eeHse#
I�sai'g A�tl�arity(carcle ane}:
1.Board of Hea1t� 2.�g Departmeat 3.Cityli'owi Cleak 4.Lioe�ng Bosrd 5.Selectnen's Office
6.0#her
Co,tact Persc�n• Pho�e#:
www.mass.gov/dia