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HomeMy WebLinkAboutApplication and WC � � a TOWN OF YARMOUTH BOARD OF HEALTH G�,�C� u`,,�L.D � APPLICATION FOR LICENSE/PERMIT-2017 p . . � ,, � � � �'-� . : � :��11� *Please complete form and attach all necessary documents by December I6 2016 Failure to do so will result in the retum of your application pac et. � �,�,� � ,,� ,;}�. � h� i��.s ESTABLISHMENT NAME: � — �-J-- LOCATION ADDRESS: � I O TEL.#: L�- ✓`=C�S�� MAILING ADDRESS: St�m6� ' E-MAIL ADDRESS: 2 Z Y' on'1 3 • f � Z ZQrt7 Cpr �Jtct .;e. ('W►9CQst n�f OWNBRNAME: %�P Qas �q�.i,�aKav��Ios ' CORPORATION NAME(IF APPLICABLE): z, LL 1viANAGER'S NAME: ' o v o TEL.#: $0 8- MAILING ADDRESS: v �D r� ttr5�'i 5 ��/! /�'1 A $ POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State taw. 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 currently certified in standard First Aid and Community � � �� Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the ?' n `f•:� employees below and attach copies of their certifications to this form.The Health Department will not use past --q , „;�:;.�,. years'records. You must provide new copies and maintain a Fle at your place of business. -- � ;`` �7 +v 1. 2. `,`J c� 3. 4. —! v� 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 fbr Food Service Establishments, 105 CMR 590.000. .� Please attach copies of certification to this application. T6e Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. '�'�`�; i. ���e,�a �� s,ma ko�o�l�.s z. �,nu�-h�n �, 1-1�b,�s PERSON IN CHARGE: { Each food establishment must have at least one Person In Chazge(PIC)on site during hours of operation. 4 � .; 1. ��i� �(aa5 �}4im!{l�'�� OT��J(oS 2.����e �(��r, I�-SiGY�dl�'��Dv�Ii�S ��� :. T- ALLERGEN CERTIFICATIONS: � � �":� Ail food service estabiislunents 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 wi}I not use past years'records. You must provide new copies and maintain a file at your estabtishment. �. An�°�-la G, �-5;ma �,��.,� �� 2.��,� l. C�1�.+�► 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�le at your place of basiness. 1. ��C k /�'��M��V� ��5 2. ��1 p�c� �. �1►k�:Ke.NOe e1�CtS 3. �b or-a. e-�,r:�s s 4. �th� �i.`6 bs ' RESTAURANT SEATING: TOTAL# 3 3 y OFFICE USE ONLY LODGING: LICENSE REQU[RED FEG PERMTT# LICENSE REQUIR�D FEE PERMIT# L[CENSE REQUIRF.D FEE PERMIT# B&B $55 CABIN $55 MOTEL 5110 INN $55 —CAMP $55 `SWIMMING POOL Sl IOea �,ODGE $55 �TRAILERPARK $105 _WHIRLPOOL S110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LIC6NSE REQUIRED FEE PERMTT# LICENSE REQUIkED FEE PERMIT ft 0-100 SEATS 5125 CONTINENTAL $35 NON-PROFIT $30 T>I00 SEATS $200 �g �COMMON VIC. $60 , ...d7� _WHOLESALE S80 —RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT q <50 sq.ft. $50 >25,000sq ft. $285 VENDING-FOOD $25 _<25,OOOsq.ft. $150 �'ROZENDESSERT S40 =TOBACCO S1l0 NAME CHANGE: $15 AMOUNT DUE _ $ 7.�C�•CXJ **•**PLEASE TUTtN OVER AIYD COMPLETE OTHER StDE OF FORM**"** (3o1fF-�5�,30�t-0Z ; � 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 INSURANCE ' AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED � OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth 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 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 piace of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and ' an aggregate of not more thazi ninety(90)days within any six(6)month period. Use of a guest unit as a residence ar 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 aze NOT allowed to sit in the pool area unti!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 FUOD SERVICE OPENING: All 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 Health Department, Downloadabie 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 CAFES: Outside cafes(i.e.,outdoor seating with waiterlwaitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: 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 RESPONSIBII.ITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVAI'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO CO CEMENT. R�NOVATIONS MAY REQUIRE A SITE P AN. DATE: SIGNATURE: - �� PRINT NAME&TITLE: � Rev.10/12/16 i � The Co»unonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aualicant Information Please Print Le�iblv Business/Organization Name;A zza,r o yac m o�� ��-c d I b 1�► -rh e�b�r ('v��t Address: (o�1 YYl ai � 5��.�- Od�'73 City/5tate/Zip:�_ Q s}. o�r rri u�t-� ►'►�)�1 Phone#: 6 b�S`� rl '15 -C�l-t 8� Are you an employer?Check the appropr'rate bog: Business Type(required): 1.❑ I am a employer with employees(full and/ 5• ❑ Retail or part-time).* 6. [�Resta.urantBar/Eating Esta.blishment 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 10.0 Manufacturing no employees. [No workers'comp.insurance required]* 11.Q Health Care 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other •Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy informalion. "*If the corporate officers have exempted themselves,but�e corporation has other employees,a workers'compensation policy is required and such an organization should check box#L I am an empdoyer rhat isprovdding workers'com,pensation dnsuraRce jor my employees Below fs the policy infornJation. Insurance Company Name: � (� ��'�t,� � ��2'('C�tl�(,11-,-�,'S' l�?C ��� -snc. Insurer's Address: �� �U,� $CJq � � z ' q 2i a+ � City/State/Zip: ��(`A.��/1�'Y`t� � �(Y� �l � � 2�S Policy#or Self-ins.Lic.#_(] 1`-�C�� 'J��3D Z,q Q 1I �0 Expiration Date: C7�b i � ZG�/7_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this sta.tement may be forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerh;j'y,under the pains and penalties of perjury that the information provided above rs true and corred. Si ature• ' Date: �� �f�/ Phon #: o� — � OJficia[use only. Do not write in this area,io be completed by czty or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: ww�v.mass.gov/dia Client#: 19049 2AZIAROYA ACORD,� CERTIFICATE OF LIABiLtTY INSURANCE °��`""""U°°"'r"' 41/t14/2016 THlS CERTIFICATE IS lSSUED AS A MATTER OF INFORMATION ONIY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE dOES NOT AFFIRMATIVELY OR NEGATlVEIY AMEND,FJCTEND OR ALTER THE COYERAGE AFFORDED BY THE POUCIES BELOW.THIS CERTtFiCATE OF iNSUFtANCE DOES NOT GONSTtTUTE A CONTRAGT BETWEEN THE 1$SUING INSURER(S},AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certiflcate holder is en ADDITtONAL INSURED,the policy(ies)mu�t be endoraed.!f SUBROGATION IS WAIVED,aub}ect to the terms and condftions of the policy,certain poticfes may require an endoraement A statement on thia certificate does not corefer rtghts to the certiflcate hoider in lieu of such endorsement{s). PRODUCER NAR9E: Dowling 8�O'Nei!Insarance Ag P"�'.No�:508 775-1620 9731yannough Rd,PO Box 9990 E,aw� ac No:50877$1218 Hyannis,MA 02801 508 775-1620 ►Ns��Rts�e�o�o�Ko coveRac� wuc o �Nsu,�aa:Mass Retaii Merchants Work Comp iNSURED INSURER B: Azzaro Yarmouth,I.LC D/B!A The�obster ! Boat Restaurant iNSURER C: i 681 Main Street,Route 28 �Ks�RER�: West Yarmouth�� Q267.3 IPI3URER E: INSURER F: COVERAGES GERT{FICATE NUMBER: REVISlON NUMBER: THIS IS TO CERTIFY THAT THE POItCIES OF lNSURANCE IISTED BE40W HAVE BEEN ISSUED TO THE IN$URED NAMED ABOVE FOR THE POLICY PERI00 INDICATED. NOTMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC7 TO WHICH THIS CERTiFICATE MAY BE ISSUED OR MAY PERTAIN, TNE lNSURANCE AFFORDEO BY TNE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALl THE 7ERMS, EXCLUStONS AND CONDITIONS OF SUCH POUCIES. UMITS SHOWN MAY FiAVE BEEN REDUCED BY PAID CLAIMS. �� TYPEQFfNSURANCE DLSU pp�,��yNt1MBER IVPA�Mt 0� M�IYWY uMtrs OEMERAL LIABILITY � � � � � � EACH OCCURRENCE 5 COMMERCIAL GENERAL LtABiLiTY PREMI E EaE�rrence a CIP.iMS-MADE �OCCUR � MED EXP t�Y�Person) S � PERSONAL 8 ADV INJURY S GENERALACaGREGATE S GEMI AGGREGATE LIMIT APPLtES PER: PRODUGTS-COMPlOP AGG $ POUCY PRO- L� : a . AUT�AOBI�E LIhB1UTY EO B��,NEnDt IN LE LI IT s ANY AUTO BODILY INJURY(Per petson) $ ALL OWNEO SCHEDULED BODILY INJURY(Per aoeident) S AUTOS AUTOS R PER DAMAUE HIRED AUTO$ AUT S��D � Per 'dent g S �����B OCCUR EP,CM OCCURRENCE S ���8 CLAIMSMADE � AGGREGATE .S � OE RETENT{ON$ g A ��°O�4PEN�"nON 014006030290146 1t01/2015 01/01/201 X �STA?U- orH. AND EMPWYER$'UABILITY ANY PROPRiETORlPARTNEWEXECUTIVE Y�N E.L.EACH ACCIDENT SGOQ OOO OFFICERIMEMBER EXGLUDED? Q N I A �Mandatory in NH) E.l.DISEASE-EA EMPLOYEE SSQO OOO If yes,describe under DESCRIPTION pF OPERATIONS below E.l.DISEASE-POIICY LIMIT SSOa OOQ �ESCRI?TION OF OPERATIONS J L�ATIONS/VEHICLES{Attech ACORD 101,Addttioaai RamaNcs Schetlule,M more space is nyuind) Operations performed by the named insured subject to poticy conditions and exclusions. CERTIFICATE HOLDER GANCElLAT10N Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRlBED POlICtES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOP, NOTICE WILL BE DELIVERED IN 7146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664-4492 aur��o�P�s�Tairv� •'�1✓/.,.o....�. 4 ir...� .. �. �t988-2010 ACORD CORPORATION.All dghts reserved. ACORD 25{2010/05) 1 of 1 1'he ACORD name and logo are reg�tered marks of ACORD #51796QT/M1 T9606 MqK