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Home My WebLink AboutApplication and WCr ' .^ � ' � TOWN OF YARMOUTA BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 *Please complete form and attach all necessary documents by D�e mb�er 16.2016. . Failure to do so will result in the return of your applicat�o' n packet. ESTABLISHMENT NAME:Holiday Vacation C'ondomini�m Tr�st T X m• �43 048 146 LOCATION ADDRESS: 488 Route 28,West Yarmouth, Ma 02673 �L#508-775-0414 MAILING ADDRESS: cama ac ahove E-MAIL ADDRESS: manager@holidayvac.com OWNER NAME: COR.PORATION NAME(IF APPLICABLE): Holiday Vacation Comdominium Trust MANAGER'S NAME: Jacqueline Howard 2oq7Zto T'EL#•508-775-0414 MAILING ADDRESS: 488 Route 28 West Yarmouth, Ma 02673 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designat Pool Operator(s)and attach a eopy of the certification to this form. _ � pt m �,_� � L Poo�fecteon swimminnepool o an 2. � `�"�- � S 4 .�i�Y � Pool operators must list a minimum of two employees currently certified in standard First Aid and Communi _,.� � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list th -,M � employees below and attach copies of their certifications to this form.The Health Department will not use pa v�� €';�� years'records. You must provide new copies and maintain a file at your place of business. � ,;�� l.Nancv Birrer 2, Jac ueline Howard 3.�eandra Dyer 4.�Simberlie Burns FOOD PROTEC"TION 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 for Food Service Establishments, 105 CMR 590.000. �l' Please attach copies of certification to this application. The Health Department will not use past years'records. '`J You must provide new copies and maietain a file at your eatablishment. � 1 N/A 2 � : - PERSON IN CHARGE: � + Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. - ��"-� 1, N/A 2 `„� : ALLERGEN CERTIFICATIONS: All food service establishments 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,l OS CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Heslth Department will aot use past years'records. You must provide new copies and maintain a t51e at your establishment. 1. N/A 2, 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 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certificarions 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. 1. N/A 2. 3. 4, RESTAURANT SEATING: TOTAL# LODGuvG: OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RMIT# sa�s Ess cnstN sss t �o�a, auo o� t(� � ass —c,v�e sss �SWIMMING POOL S110ea��---��—oY, �oµ�-t S-��y�-o�z _LODGE a55 =TRATLERPARK $105 �WHIRLPOOL $110ea. �� gpµSP��S�I?y7-0Z FOOD SERVICE: CD�I K�HSP"�S�(7�$p2. LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REp U[RED FEE PERMIT# 0-100 SEATS a125 _CONTINENTAL $35 NON-PROPIT $30 �P SO�S P—�$—��q�,�� >100 SEATS $200 _COMMON VIC. S60 WHOLESALE S80 RETAIL SERVICE: —RESID.KITCHEN S80 LIC&NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 s�q.ft. S50 >25,000 sq.ft. 5285 VENDING-FOOD $25 <ZS,OOOsq.ft $150 �ROZENDESSERT$40 _1'OBACCO 5110 NAME CFIANGE: $IS AMOUNT DUE _ $ �4 Q.�U "*"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM°*+*" , , ADMINISTRA.TION 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.AFFIDAVII'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 MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCI': For purposes of the limitadons of Motel or Hotel use,Transient cecupancy 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 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 Departrnent prior to opening. Contact the Health Deparnnent to schedule the inspection three(3) days prior to opening.PLEASE NOTE:People aze NOT allowed to sit in the pool area 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: Atl 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.varmouth.ma.us under Heaith 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 CAF�S: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health i OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. i � � � NOTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTf Y TO RETURN ; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ; � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL O POOL (i.e., PAINTING, NEW ( { EQUIPMENT,ETC.), ST BE REPORTED TO D APPftOVED BY BOARD OF HEALTH PRIOR I TO COMME C ME . RENOVATIONS MAY UIRE A E PLA DATE: � SIGNATURE: PRINT NAME&TITLE: �X ' (J � �� Rev.10/ILl6 , E I • -'�� HOLIVAC-01 H A�� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YYYY) 10/21/2016 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 certi£cate 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 conditions of the policy,certain policies may require an endorsement. A statement on this ceRificate does not confer ri hts to the certificate holder in lieu of such endorsement s. PRODUCER C NTACT Rogers&Gray Insurance Agency�IflC. PHONE ac,No:(877)876-2156 434 Rte 134 ac,No,e�: South Dennis,MA 02660 � �� .mail rogersgra .com INSURER S AFFORDING COVERAGE NAIC# �r,suReRn:Acadia lnsurance Com an 31325 INSURED INSURERB:TfaV@I@f'"S Ifl8Uf8I1C@ CORI anies Holiday Vacation Condominium Trust INSURER C: PO BOX 94O INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POIICiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTiMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1MTH 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 OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g �,OOO,OOO CLAIMS-MADE �OCCUR CLA5079655-13 01/18/2016 01/18/2017 DAMAGE TO RENTED $ 250,00� MED EXP An one rson 5,000 PERSONAL&ADV INJURY $ �,OOO,OOO � GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE 2,000,000 POLICY❑X jE�a ❑X LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: AUTOMOBILE LIABIIJTY COMBINED SINGLE LIMIT $ ANY AUTO BOOILY INJURY Per erson ONMED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Peraccident $ AUTOS ONLY AU�TOS ONL� P�O�Rd�� AMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S,OOO,OOO EXCESSLIAB CLAIMS-MADE CUA5079658-13 01/18/2016 01/18/2077 qGGREGATE $ DED X RETENTION$ 0 Aggregate 5,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y�N A�FPICER/MEIMB�ER/EXCLUDED?ECUTNE ❑ N�A (Mandatory In NN) E.L.EACH ACCIDENT If yes,describe under E.L.DISEASE-EA EMPLOYEE DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT B Directors&Officers 105944287 O6/15/2016 06/75I2017 Directors&Officers 1,000,000 DESCRIPTION OF OPERA710NS/LOCATIONS/VEHICLES(ACORD 101,Addttlonal Remarks Schedule,may be attached It more space is isquired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRiBED POLICIES BE CANCELLED BEFORE TOw11 Of YaRIIOUth THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED fN 1746 ROUt6 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE �/� �/�/� ACORD 25(2016/03) OO 1988-2075 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD