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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH : �� APPLICATION FOR LICENSE/PERMIT-2017 £•.'� *Please complete form and attach all necessary documents by December l6 2016. Failure to do so will result in the return of your application pac et. ESTABLISHMENTNAME: f'�[RA-1�� Cc�v� rYL4�C1CiE.T►'J�.�1-C� TAX ID: C7�-/3 --3��—9�c� LOCATIONADDRESS: `�7 �IZ /'V1R CN ST � ��Y�rCMoy11'f' TEL.#: �'Z3Y' �9Y'�2S'Z. MAILING ADDRESS: G�L fe a Y E-MAIL ADDRESS: Cc�v'� S�C•Le-Q r C-�W` OWNERNAME: l�i vl�e.•r'f t—Cc�-d L.n'f`e— CORPORATION NAME(IF APPLICABLE): Y�'Q�iY�I�-C'�. h'i'�P(kA-�S �� tN��' MANAGER'S NAME: c1 IOP�.-�''f-COwe( TEL.#: �Zi''L MAILING ADDRESS: � 'I'Z vv�s�t ni S� S•`{ Y�-�e ry�]�!r�f� C�Z(sb y POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees cuxrently certified in standard First Aid and Community ?: � Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the 'n °"'" employees below and attach copies of their certifications to this form.The Health Department will not use past '-' - �,' fi'"'4 years'records. You must provide new copies and maintain a file at your place of business. -I � `%� y w } 2. :� E 3. 4. ��.� - �;� --i ��. �� FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who is certified as a Food -`�`�"Y"�`-`�"� 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. �; ; �s. 1. �17✓r� � � f'�.� 2. � � �� PERSON 1N CHARGE: � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � i. ��--,.� ( (..�,�-e.. 2. � � _.o ALLERGEN CERTIFICATIONS: �.� ..� All 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 attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a Sle at your establishment. 1. � � �N¢''- 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. Piease 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 your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# �-� do�+FaS-(376-crL OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _B&B $55 CABIN $55 MOTEL $ll0 INN $55 CAMP $55 SWIMMING POOL SI l0ea _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: �CENSE REQUIRED FEE ERMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS a125��75 CONTINENTAL $35 NON-PROFIT S30 >t00 SEATS $200 �COMMON VIC. $60 �� =WHOLESALE S80 —RES[D.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE �RMIT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �<25,OOOftsq.ft. $�50 O�� FROZENDESSERT$$40 �S _TOBACCp FOOD$$4o IYAMECHANGE: SIS AMOUNT DUE = S � �� 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 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 prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations 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 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 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 azea 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. T'hese forms can be obtained at the Health Depaztment,or from the Town's website at www.yannouth.ma.us under Health Departrnent, 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 Departrnent. 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 Boazd of Health. ; OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITI'TO RETURN THE COMPLETED RENEWAL APPLICATION(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 I TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. ' DATE: Na�(�r�l� SIGNATURE: !%' Y � � PRINT NAME&TITLE: ��C..C� � L.�J l��C (/1/ Y�,/ Rev.l0/12/l6 ' � The Commonwealth of Massachusetts Department of Industrial Accidents O�ce of Investigations � 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Information Please Print Le�iblv Business/Organization Name: � � � � ��Z- ��'� �A-��-' Address: � � Z V� �N S� /�u v r-�Z� City/State/Zip: Sl��J�l f- �(r4-�-+�/l��'f P e#: ��'� �J� `� ` s 2 S � Are you an employer?Check the appropriate boz: Business Type(required): 1.�am a employer with / employees(full andl 5. �].R�il or part-time).* 6. ❑ RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sa1es(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]* 4.❑ We are a non-profit organization,staffed by votunteers, 11.�Health Care with no employees. [No workers' comp.insurance req.] 12.� Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. "If the corporate officers have exempted themselves,but the corporation has othex employees,a workers'compensation policy is required and such att organization should check box#1. I am an employer that is providing workers'compensation insurance for my emp[oyees Below is the policy informatioir. Insurance Company Name: ��+E'.�t"� I�S ty YL.9 dv't�� /Q.�l�� Insurer's Address: y�� S�� /� � �� S � City/State/Zip: m l I� t✓��✓�i7 � l�!L� � '�� C� Policy#or Self-ins.Lic.# W� �Z 3 �'� � Expiratian Date: �� f`��'` Attach a copy of the workers'compensation policy declaration page(showing the policy number and ezpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz 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 kereby certi ,under the pains and penalties of perjury that the information provided above is true and correc7. Si¢nature: O �' V'�- Date: /v v ''� �� C' Phone#: ��8 ' � �, Y- S 2 S Z' Official 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.govldia �� PCMAN-2 OP ID:KM ACORO" DATE(MMIODNYW) �� CERTIFICATE OF LIABILITY INSURANCE 17/78/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N 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 SUBROGA710N 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 Karl T.leuter leuter Insurance Group PHONE Fax 414 Townsend St P.O.Box 552 ac No e�:989-835-6707 �vc No:989-835-2964 Midland,MI48640 A DRE55:kal'I ieuter.com Karl T.leuter INSURER S AFFORDING COVERAGE NAIC# iNsuReRn:T.H.E.Insurance Co INSURED Pirates Cove East INSURER B: 728&742 Main St,South INSURERC: South Yarmouth,MA 02664 INSURER D: INSURER E: 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. . INSR 7ypE OF INSURANCE ADDL SUBR pOLICY NUMBER MMIDDIYWY MMIUDD/YYW LIMITS LTR COMMERCIAL GENERAL LIABILITY � EACH OCCURRENCE $ � CLAIMS-MADE � OCCUR PREMISES Ea occTu ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY� PR� � LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ AUTOMOBIIE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PeOa�R�TnDAMAGE $ HIREDAUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION �( AND EMPLOYERS'LIABILITY STATUTE ER H A ANYPROPRIETOR/PARTNER/EXECUTIVE Y� WC123697 01/01I2017 01/01/2018 E.L.EACHACCIDENT $ ��OOO�OO OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ �,0��,�0 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OO DESCRIP710N OF OPERATION5 I LOCAiIONS I VEHICLES (ACORD 107,Additional Remarks Sehedule,may be altached if more space is required) CERTIFICATE HOLDER CANCELLATION TOWNY-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth TNE EXPIRATION DATE THEREOF, NO710E WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE �•� �'_�,� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD