HomeMy WebLinkAboutApplication and WC a TOWN OF YARMOUTA BOARD OF HEALTH
��� APPLICATION FOR LICENSE/PERMIT-2017 , �
`� *Please compiete form and attach all necessary documents by December 16.2016.
Failure to do so will result in the return of your application packet.
ESTABLiSHMENT NAME: e o t e ea T • 0 - �
� LOCATION�DxESS: 3 out ore r So, armo L.#: 8-3A8-2288
' MAILINGADDRESS: Nort Main st. So. Yarmouth, MA 02664
E-Mar1,,�wDxEss: mpurrier e avenportcomranies.com
OWNER NAME: ue ater
CORPORATION NAME(IF APPLICABLE):
MANAGER'S NAME: John Verit TEL.#: 08-398-2288
MATLINGADDRESS: Nort Main St. , So. Yarmouth� MA 02664
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pooi Operator,as reqaired by State law. Please list the designated
Pool Operator(s)and attach a copy of the certification to this form.
1, Will Provide prior to opening 2. _ :�w. �
--
—— ---- ------------_
m �-:
___
Pool operators must list a minimum of two employees currently certified in standard First Aid and Commuruty �� �
Cardiopulmonary 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 wilt not use past � ��
years'records. You must provide new copies and maintain a file at yonr place of business. � �
IT1 -::r, �
1. 2. � � � �_;::�
3. 4. -i �� �
FOOD PROTECTION 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. k;
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 ffle at your establis6ment. ,` �
1. _ - _ 2. �
PERSON IN CHARGE: p
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ' �
...i�
1. 2. t? �'
ALLERGEN CERTIFICATTONS: `
Ail food service establishments aze 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 atEach
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. Will provide prior to opening 2.
HEIMLICH CERTTFICATIONS:
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 certifications to this form. The Health Deparhnent will not use past years'records.
You must provide new copies and maintain a file at your place of business.
1. Wi 11 nr,� �vi��nri nr tn nr�Pni po 2.
3. a 4.
RESTAUR.ANT SEATING: TOTAL#
OFFICE USE ONLY
LODGING: p L�y�
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P RM1T# � � ��3
B&B �55 _CABIN S55 �MOTEL SI10 �
—INN S55 CAMP $55 _SWIMM[NG POOL$1 l0ea.
_LODGE $55 TRAILERPARK 5105 _WHIRLPOOL S110ea
FOOD SERVICE:
LICENSE RE UIItED fEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-t00SEA�S $125 _CONTINENTAL $35 NON-PROFIT $30
>t00 SEATS 5200 COMMON VIC. $60 WHOLESALE S80
— —RESID.KITCHEN S80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUTRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sG.ft. $50 >25,000 sq.ft. 5285 VENDING-FOOD S25
_<25,000 sq.ft. $150 —FROZEN DESSERT$40 _TOBACCO 5110
NAME CHANGE: S15 AMOTJNT DUE _ $ ��[/e�(.�
"*+'�*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 ATTACFI�D STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OP'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
MOTELS AND OTHER LODGING ESTABLISIiMENTS
- -- - -TRANSIENT OGCUPANCY: Forpurposes of the limita6ons of Motel or Hotel use,Transient occupancy shail 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
�xcise,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 area until the pool has been
inspected and opened.
POOL WATER TESTING: T'he 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 tb 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 OPEMNG:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Depaztment to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yannouth 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 CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Health
j OUTDOOR COOHING:
Outdoor cooking,preparation,or dispiay 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 RESPONSIBILTTI'TO IZET'[JRIV
; THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ±
ALL RENOVATIONS TO ANY FOOD ESTABLISFIMENT, MOTEL OR POOL (i.e., PAINTING, NEW i
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY TF-iE BOARD OF HEALTH PRIOR I
TO COMMENCEMENT. RENOVATIONS A SITE P . ,
DATE: 11/1/16 SIGNAN . C�' \
PR1NT NAME&TITLE:�I a r v P �� r r i P r��.c c i c t an t--r o���e-�1 e r
Rev.l0/IZ/16 ! '
'. i
� The Commonweatih ofMassachusetts • '
Department of Industrial Acciderxts
Office of Investigations
` 1 Congress Street, Suife 100
Boston,MA 02II4-2017.
www.naass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le�iblv
Business/OrganizationName: Ed�e of the SPa / R7 „e W�rA,-
Address: 301 South ShoreDDrive
City/State/Zip: So.Yarmouth,MA 02664 Phone#: 5�f�-�AR-��g� . __. ___
Are you an employer?Check the apprapriate boz: Business Type(required):
1.� I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑ RestaurantlBaz/Eati.�g Establishment
2.❑ I am a sole proprietor or partnership and have no �, � O�ce and/or 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.�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 S e a s o n a 1 R e s o r t
tAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
"'�If the corpornte 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 rhal is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Zur�bh American Tn c ('n
Insurer's Address: S e e a t t a ched
City/State/Zip:
Policy#or Self-ins.Lic.# WC 819 6 0 3 5 Expiration Date: 3-1 -1 7
Attach a copy of the workers'compensatian policy declaration page(showing the policy number and ezpiration 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 VJORK 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 r ' under the pains penalties of perjury thal the inforrnation provided above is true and correc�
Si ature• Date: 11-1-16
Phone#: 508-398-2293
Officia[use only. Do not write in this area,to be completed by city or town officiaL
City or Town: PermitlLicense#
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#:
ww�v.mass.gov/dia
ACORD� . DAl'E(MM/DD/YYYY) .
�� CERTIFICATE OF LIABILITY INSURANCE 3/9/2016
THIS CERTIFICATE IS ISSUED AS A MATT'ER 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), AUTHORI2ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTAN7: 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 Kristina Converse
' E. K. McConkey&Co. (Valley Forge) PHONE Fax
� 2555 Kingston Road, Suite 100 '
' York PA 17402 E�'''"'� ,kconverse@vfcadvisors.com
INSURER S AFFORDING COVERAGE NAIC#
i wsuReRa:Zurich American 16535
� INSURED DAVEN-1 � wsuReR s: �
Blue Water LP INSURERC:
c/o Davenport Realty Trust
20 North Main Street INSURERD:
' South Yarmouth MA 02664 INSURERE:
� INSURER F:
COVERAGES CERTIFICATE NUMBER:205254272 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
i INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
I 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 7ypE OF INSURANCE POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DDIYYYY MM/DD/YYW
A x COMMERCIAL GENERAL LIABILITY GL08196255 3/1/2016 3/1/2017 EqCH OCCURRENCE $1,000,000
i CLAIMS-MADE �OCCUR PREMISES Ea c urrence 3500,000
i MED EXP(Any one person) 51,000
PERSONAL&ADVINJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 52,000,000
POLICY❑ PR� � LOC PRODUCTS-COMP/OP AGG S
JECT
OTHER: $
A AUTOMOBILE LIABILITY BAP8196256 3/1/2016 3/1/2017 Ea accident $1,000,000
. X ANY AUTO BODILY INJURY(Per person) $
AUTOS JE� AUTOSULED BODILY INJURY(Peraccident) $
x HIREDAUTOS x NON-OWNED pR PER YDAMA E $ �
AUTOS Per accident
$
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS IIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ 8
q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 x
AND EMPLOYERS'LIABILITY Y�N STATUTE ERH
ANY PROPRIETOR/PARTNERJEXECUTIVE ❑ N�A E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERAT�ONS 1 LOCATIONS/VEHICLES �ACOR�101,Additfonal Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS.
Route 28
South Yarmouth MA 02664 USA qUTHORIZED REPRESENTATIVE
�.�%�r��—�"'�
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORO name and logo are registered marks of ACORD