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Home My WebLink AboutApplication and WC a TOWN OF YARMOiJTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2017 " *Please complete form and attach all necessary documents by December 16.20I6. Failure to do so will result in the return of your application packet. ESTABLISHMENTNAME: irwoo ace TAXID:�4-h572Q�,�, � LOCATIONADDRESS: 237 North Main St. SO.Ya TEL.#: ' MAILING ADDRESS: or in t. out armout MA 0266 E-Mar1,aDDxESs: mpurrier thedavenportcom�anies.com OWNER NAME: CORPORATION NAME(IF APPLICABLE): MANAGER°S NAME: war �odwiu_ TEL.#: ��c�.g�� MAILINGADDRESS: or a1�in St. , So. Yarmouthr� M,4 ��h(�[ _ - - � POOL CERTIFICATIONS: D �A"±�:= � The pooi supervisor must be certified as a Pool Operator,as required by State law. Please list the designated `-- � Pool Operator(s)and attach a eopy of the certification to this form. _ -�- � 1 Attached 2. �'�` o , � -� _.___� _ � __ Pool operators must lisf a minimum of two employees currently certified m standazd First A'id and Communiry- .� �..� � Cardiopulmonary Resuscitation(CPR),having one cemfied employee on premises at all times. Please list the employees below and attach copies of their cert�cations to this form.The Health Department wil!not use past years'records. You must provide new copies and maintain a file at yonr place of business. i. Attached 2. 3. 4. �:e;�� FOOD PROTEC'I'ION MANAGERS-CERTIFICATIONS: '' „a� , All food service establishments are required to have at least one full-time employee who is certified as a Food g__ Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. 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. �` � k- � „ 1, Attached 2. , � �=� PERSON iN CHARGE: ��"` ,�� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. -�^' 1 Attached 2. ALLERGEN CERTIFICATTONS: 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,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 t"ile at your establishment. i. Attached 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 certifications to this form. The Health Department will not use past years'records. You must provide new copies and maintain a file at yonr place of business. 1, AttachPd 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY (�)�o�SP-t`�-b�J47-03 LODGING: LICENSE REQUIRED FEE PERMIT i� LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#��6}jSP�I�F-o398-�3 _B&B $55 CABIN $55 MOTEL 5110 INN $55 —CAMP $55 �SWIMMINGPOOLallOea 100' _LODGE a55 =TRAILERPARK $105 WHIRLPOOL a��o�. go�}F-��-O'Z�$-Q"�j FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $12S CONTINENTAL $35 NON-PROFIT $30 �>l00 SEATS 5200 �2 �COMMON VIC. $60 �"j —"WHOLESALE S80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT il <50 sq.ft. S50 >25,000 sq.ft. 5285 VENDING-FOOD S25 Z,�15,000 sq.R. S150 �L3 =FROZEN DESSERT$40 _TOBACCO 5110 NAME CHANGE: �IS AMOUNT DUE _ $ ��d��C� *****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 ATTACI�D STATE WORKER'S COMPENSATTON INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.Or 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 ESTABLISHMENTS -- -- -- TRANSIENT OGCUPANCY:-For purposes of the limitations of Mote1 ar Hotel use,Transient occupancy 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 �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 Departrnent 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 i 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 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 OPE1vING: 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 Departrnent,or from the Town's website at www.�armouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthiy 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,prepazation,or display of any food product by a retail or food service establishment is prohibited. ; � NOTICE:Pemuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILTTY TO RETURN ; THE COMPLETED RENEWAL APPLICATTON(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ; ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW i EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR � TO COMMENCEMENT. RENOVATIONS QUIRE A SITE PLAN� ' DATE:, 11/1/16 SIGNATU . ` ' ,/ti(/�c./li�� PRINTNAME&TITLE: Marv Pi�rr�' Pr� E1,cc; stant �en��-�ler ' Rev.f0/12/l6 i : i 1 � The Commonwealth of Massachuseits " Department of Industrial Accidents Office of Invesfigations ' 1 Congress S'treet, Suite 100 Boston,lYfA 02114-20I7. www.mass.gov/r�ia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: Thirwood Place Address: 237 North Main St City/State/Zip: So.Yarmouth.�MA 026h4 Phone#: 508-398-8006 Are you an employer?Check the appropriate boz: Business Type(required): 1.[� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestaurantlBar/Eatz*�g Establishment 2.❑ I arn a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.} employees working for me in any capacity. [No workers' comp.insurance required] g• ❑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 10.0 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 R P t i remen t �ommt��i t *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatioa policy information. **If the corponte office�s 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 emp[oyer ihat is providing workers'compensation insurance for my employees Below is the policy information. InsuranceCompanyName: Zur�b.h American Tnc ('n Insurer's Address: S e e a t t a ch e d City/State/Zip: Policy#or Self-ins.Lic.# WC 819 6 0 3 5 Expirati�n Date: -1 -1 7 Attach a copy of the workers'compensation poficy declarafion paae(showing the policy number and ezpiration date}. Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the ixnposition 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 DIA for insurance coverage verification. I do hereby ce under the pains a enalties ofperjury that the information provided above is true and correct. Si ature• �/ �l�/�� Date� 11-1-16 Phone#: 508-398-2 93 Official use only. Do not write in this area,to be completed by cify or town officiaL City ar Town: Permit/License# 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#: www.mass.gov/dia ACO� DATE�MMIDD/YYYY) �� CERTIFICATE OF LIABILITY INSUI�ANCE 3/9/2016 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 NAME:CT Kristina Converse � E. K. McConkey&Co. (Valley Forge) P"o"E ,484-965-9623 F"" .484-965-9627 2555 Kingston Road, Suite 100 E-Mai� ,kconverse vfcadvisors.com York PA 17402 @ INSURER S AFFORDING COVERAGE NAIC# iNsuReRn:Zurich American 16535 INSURED DAVEN-1 INSURER B: Thirwood Place L.P INSURER C: c/o Davenport Realty Trust iNsuReR o: 20 North Main Street South Yarmouth MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1985566335 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. ��7� NPE OF INSURANCE INSD WVD POLICY NUMBER MM/�UY� MMIDD� LIMITS A X COMMERCIAL GENERAL LIABILITY GL08196255 3/1/2016 3/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X�OCCUR DAMAGE TO EN D PREMISES Ea occurrence 5500,000 MED EXP(Any one person) 51,000 PERSONAL&ADVINJURY $1,000,000 GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $2,000,000 POLICY❑ PR� �LOC PRODUCTS-COMPIOPAGG 82,000,000 JECT OTHER: S A AUTOMOBILELIABILITY BAP8196256 3/1/2016 3/1/2017 Eaaccident $1,OOO,D00 X ANY AUTO BODILY INJURY(Per person) $ AUTOS�ED AUTOSULED BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED P P DAMA E $ AUTOS � Per accident 8 UMBRELLALIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ . DED RETENTION$ $ q WORKERS COMPENSATION WC8196035 3/1/2016 3/1/2017 PER OTH- AND EMPLOYERS'LIABILITY � Y�N x STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACHACCIDENT E1,000,000 OFFICER/MEMBER EXCLUDED7 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE E1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 107,Additional Remarks Schedule,may be attached 1f 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 TOWfI OP Y8f1110UtI1 ACCORDANCE WITH THE POLICY PROVISIONS. Route 28 South Yarmouth MA 02664 USA AUTHORIZED REPRESENTATIVE �'j�y��-�- O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD