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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 16 2016. Failure to do so wi(1 result in the return of your applicauon pac cet. ' ESTABLISHMENT NAME: w I ow+ # 0 6 a LOCATION ADDRESS: O / o u� ? ,.. �,w► a66 TEL.#: S'a - —1�a S MAILING ADDRESS: .o e�r O/ ' I L o / E-MAIL ADDRESS: X ICEI1S�tC @1d18 S W8 f�11S.001F1' OWNER NAME: o� y'eer. �.s'f�rr+ Ce. C. CORPORATION NAME(IF APPLICABLE): Wo,1•�r�-e.�. �as�'trK C•. 2�+ C. � MANAGER'S NAME: .�, r �h:� TE .#: • 4 - ! a S MAILINGADDRESS: �d• o� aYo1 GCr e /t+l 2L 6'4e/S m � �''' D ('rn') ��> POOL CERTIFICATTONS: � � �A` The pool supervisor must be certif ed as a Pool Operator,as required by State law. Please list the designated Z w �: Pool Operator(s)and attach a eopy of the certification to this fonn. �-7 ,;: �. N//9" 2. :�� o �: � � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community , � Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their cerrifications to this form.The Health Department will not use past years'records. You must provide new ce}�ies and maintain a file at your place of business. _ __ l. �� 2. 3. 4. �""`�� FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food �� Pmtection Manager,as defined m the State SaYutary Code for Food Service Establishments, 105 CMR 590.000. W Please attach copies of certification to this application. The Health Department will not use past years'records. � p You must provide new copies and maintain a file at your establishment. i, �� Pre �c�c., d( �au a� Q� ( z. . �-� PERSON IN CHARGE: y � � Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ��,�<_` 1._ _/'7kt o'1✓��✓ ��l i��sf J� -�`�. /�Y 2. .�1 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 Fstablishments,105 CMR 590.009(Gx3xa). 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 tile at your establishment. , �. �/l� 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 a(1 times. Please list your employees trained in anti-chokmg procedures below and attach copies of emptoyee certifications to this form. The Health Department will not use past years'records. You must provide aew copies and maintain a file at your place of business. �. N.l� 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGWC: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# B&B S55 CABIN S55 MOT'EL 5110 INN a55 CAMP S55 SWIWIhiING POOL S110ea =LODGE S55 _TRA[LERPARK 5105 _WHIRLPOOL S110es. FOOD SERVICE: LICENSE REQ UtRED FEE PERMIT# LICENSE REQUiRED FEE PERMIT# LICENSE REQ UIRED FEE PERMIT# 0-l00 SEA'1'S 5125 _CONfINENTAL S35 NON-PROFIT S30 >I00 SEATS 5200 _COMMON VIC. S60 —WHOLESALE S80 — —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq R. S50 >25,000 ft. 5285 VENDING-FOOD S25 �<ZS,DOOsq.ft, SI50 �� -FROZEN�ESSERT S40 _TOBACCO SI10 NAME CHANGE: S15 AMOiJNT DUE = S /S O.0 Q :"•••pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•••"* ��'L��I 5.. (p Z� !�`� vfS . � 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 Cert�cate 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.AFFIDAVTI'SIGNED AND ATTACHED '� Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPWATELY IF PAID: / YES �/ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitarions 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 place of residence elsewhere.Transient occupancy shall gen�rallyrefer to continuaus 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: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Departrnent three(3)days prior to opening,and quarterly thereafter. • POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven('n days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health DeparEment prior to opening. Please contact the Health Departinent to schedule the inspection tlu�ee(3)days prior to openmg. 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.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opemng 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 undl 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. ; 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. TT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. i ALL RENOVATTONS 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 MAY REQUIRE A SITE PLA� ' ,', i DATE: DEC O 6 ZO�u SIGNATURE: PRINT NAME&TITLE: 6�er Martira�rz- Rev.10/l2/16 license Special�st , �4�-527-424�1, � � � � The Commonwealth of Massachusetts Depart»�ent of Industrial Accidents O�ce of Invesiigations � 1 Congress Street,Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Analicant Inform�tion Please Print Le�iblv Business/Organization Name: Woi�Ay� ��r.� �o, �..C �(� i�,�a(.+'1^e�^S � /O y.�0 Address: 1 D�� /CO u�� a o City/State/Zip: .S. yq✓,A,�f�+ ��f�' �Dal�'y Phone#: ��o— ��( — � 3� � Are you an employer�Check the appropriate bog: Business Type(reqnired): 1.[�I am a employer with oZ� employees(full and/ 5• ❑Retail or part-time).'` - — b. ❑ Restaurant�arlEating Establishment __ _ 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real esta.te,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]* 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, ��1 ti ,/� 1 , with no employees. [No workers' comp.insurance req.] 12.["rOther �'�171.� l/✓'� 57D�^�f"��'+�r,eS •Any applicant that checks box#1 must also fill out the sec6on below showing their workers'compensation policy information. •*If the corpoiate officers have exempted themselves,but the corporation has other employees,a worlcers'compensation policy is required and such an organization should chedc box#1. I am an employer that�tsproviding workers'cor»pensation Insurance fo'r my�►nployees Below is the policy information. Insurance Company Name: / o� S� �e a �'� Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy namber and ezpimtion date). Failure to secure coverage as required under Section 25A of MGL a 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties ofperjary that the information provided above�s true and correc:� � 9 � �- R�ger Martth�zz p�, DEC 0 6 2016 si�`�re• � �rtse-sp�cfian�t Phone#: 847-527-4249 Official use only. Do not write in thu area,to be completed by city or town offaciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Hea1tL 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia ♦ � • �� fi " � ,��g y f Y:'. '� r,:..,�,w ' 'y;. PRODUCER � THIS MEMORANDUM IS ISSUED AS A MATTER OF INFORMATION ONLY TO AUTHORI2ED MARSH USA INC VIEWERS FOR THEIR INTERNAL USE ONLY AND CONFERS NO RIGHTS UPON ANY VIEWER 540 W.MADISON OF THIS MEMORANDUM OTHER THAN THOSE PROVIDE FOR IN THE POLICY. THIS CHICAGO,ILLINOIS 60661 MEMORANDUM DOES NOT AMEND, EXfEND OR ALTER THE COVERAGE DESCRIBED UNITED STATES OF AMERICA BELOW.THIS MEMORANDUM MAY ONIY BE COPIED,PRINTED AND DISfRIBUTED WITHIN AN AUTHORIZED VIEWER AND MAY ONLY BE USED AND VIEWED BY AN AUTHORIZED VIEWER FOR 1T5 INTERNAL USE. ANY OTHER USE, DUPLICATION OR DISTRIBUTION OF THIS MEMORANDUM WITHOUT PRIOR WRIfTEN CONSENT IS PROHIBITED. INSURED � � „� , � � COMPANY ZURICH AMERICAN INSURANCE COMPANY 16535 WALGREEN CD.AND 5UBSIDIARIES A 300 WILMOT RD.,MS#3108 COMPANY XL INSURANCE AMERICA,INC. 24554 DEERFIELD,ILLINOIS 60015-5223 B UNIfED STATES OF AMERICA COMPANY AMERICAN ZURICH INSURANCE COMPANY 40142 C COMPANY SELFINSURANCE . _ D . � a � , ��r �,.. a ,. ��.. . ., �_ � � � � � � s� 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 CONIRAGT OR OTHER DOCUMENT W1TH RESPECT TO WHICH THIS MEMORANDUM MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITi0N5 OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .. r ��., ��'" s;' r.k, A GENERAL LIABILITY GLO 9310091 13 7/1/2016 7/1/2017 X coMMERCIA�GENERa��[Aei�rrv GLO 9310184 13(Puerto Rico) 7/1/2016 7/1/2017 GENERAL AGGREGATE 5 000 000 CLAIMS MADE QX oCCUR PERSONAL Ni ADV IWURY 4 D00 D00 X Blanket Additional Insured EACH OCCURRENCE 4 000 000 X Per Policy FIRE DAMAGE An One Fire 500 000 X Blanket Contradual Liability MED DCP An One Person 0 X Liquor Liability A AUTOMOBILE LIABLLTTY BAP 9310096 13 7/1/2016 7/1/2017 X ANY AUTO COMBINED SINGLE LIMIT $ 5,000,000 ALL OWNED AUTOS BAP 9310183 13 (Puerto Rico) 7/i/2016 7/1/2017 SCHEDULED AUTOS BODILY INJURY(Per PerSon) $ HIRED AUTOS NON-OWNED AUTOS BODIIY IN]URY(Per ACcident) $ PROPERN DAMAGE $ B EXCESS LIABILITY US00075933LI16A 7/1/2016 7/IJ2017 EACH OCCURRENCE 5 000 000 X UMBRELLA FORM AGGREGATE 5 000 000 OTHER 7HAN UMBRELLA FORM C WORKERS COMPENSATION/ WC 9310092-13(AOS) 7/1/2016 7/1/2017 WORKERS COMPENSATION A EMPLOYERS LIABILITY WC 9310094-13(WI) LIMITS STATUTORY A EWS 9310093-13(IL&LA) q PARTNERS/EXECUIIVE_ ]( INCL EWS_�14a4�.,13�,-r-- .. _.., _�. � . - �-. -. �tEsO�'c.��ENT __.,._� .� - . ... . 7-.�nr�ru� . q o��c��s ARE: ocC�. EWS 93f6v48-13(MA&TN) �� EL DISEASE-POtICY LIMIf 2 000 000 EL DISEASE-EACH EMPlOYEE 2 000 000 D PRODUCT I.IABI ITY Self-Insured 7/1/2016 7/1/2017 EACH OCCURRENCE 2 000 000 AGGREGATE 2 000 000 OWNERS/LESSORS/LANDLORDS AND THEIR RESPECTIVE AGENTS,LENDERS,MORTGAGEES,GROUND LESSORS, VENDORS,CUSTOMERS,CLIENTS,AND ANY OTHER PARTIES ARE AUTOMATICALLY ADDED AS ADDITIONAL INSURED AND/OR LOSS PAYEE AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. THE ABOVE POLICIES IN0.UDE AN AUTOMATIC WANER OF SUBROGATION AS REQUIRED BY A SIGNED LEASE,CONTRACT OR OTHER WRITTEN AGREEMENT. �. ._ .._ ... , . � _ � _ �. !,