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Home My WebLink AboutApplication and WC o� � TOWN OF YARMOUTH BOARD OF HEALTH C O � LICENSE/PERMIT-2017:' . R E C E I V�D � *Please complete form and attach all necessary d '° ts b � � n 7 Failure W do so will result in the retum of your application packet. ��g'j � � 7'1�1 ESTABLIS�IlvIENT NAME:Hun Inc. dba Beef Jer Outlet TAX ID: LOCATION ADDRESS:525 Route 28 West Yarmouth MA 02673 TEL.#:54 - MAILING ADDRESS:525 Route 28 West Yarmouth MA 02673 E-MAILADDRESS:caahuntna.aol_com OWNERNAME:WilliamHunt � CORPORATION NAME(IF APPLICABLE):Hunta,Inc. , MANAGER'S NAME: William Hunt TEL.#:540-494-3461 MAIL.ING ADDRESS: Z512 Highland Tenace,Plyrnouth,MA 02360 POOL CERTIFICATIONS: The poo{suQervisor 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 certificarion to this form. 1. N/A 2. Pool operators must list a minimum of two employees currently certified in standazd First Aid and Community Cardiopulmonary Resuscitation (CPR),having one certified employee on premises at a11 times.Please list the employees below and attach copies of their 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. L N/A 2. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishtnents 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. Please attach copies of certification to this application. T6e Heatth Departmentwill not usepastyears'records.Yo1�must provide eew copies and maintain a file at yourestablishment 1. N/A 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. l. N/A 2. ALLERGEN CERTIFICATIONS: Ail 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(Gx3)(a). Please attach copies of certificarion to ttris application T6e Health Department will not use past years'records.You must provide new copies and maintain a file at yourestablishment 1. See Attached 2• HEIMLICH CERTIFICATIONS: All food seroice establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at a11 times. Please list yow employees trained in anti-choking pmcedures 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 ofbusiness. 1. N/A 2. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIItID FEE PIItMIT# LICENSE REQUIItED FEE PERMIT# LICENSE REQUIItID FEE PERMIT# TB&B S55 _CABIN $55 _MOTEL 5110 _INN $55 _CAMP $55 ,SWIlvIIvIING POOL $110ea. ,LODGE S55 T'fRAII.ER PARK $105 _WHIIiLPOOL �110ea. FOOD SERVICE: LICENSE REQUII2ED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRID FEE PF,RMIT# _0-100 SEATS $125 _CON'PINEN'PAL E35 _NON-PROFIT $30 _>I00 SEATS 5200 _COMMON VIC. S60 WHOLESALE $80 ,RESID.KITCHEAI S80 RETAIL SERVICE: LICENSE REQ[JIRED FEE PERMIT# LICENSE REQUIItID FEE PERMIT# LICINSE REQUIItID FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �<25,000 sq.ft. S150 �� _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: S15 AMOUNT DUE _ $ 15 Lf1..O O *****PLEASE TORN OVER AND COMPLETE OTI�R 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 INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURANCE ATTACHED: Yes OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth t�es and liens must be paid prior to renewal or issuance of your permits.PLEASE CHECK APPROPRIA'I`ELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS T'RANSIENT OCCiJPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordinatily 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 occupancyshall generallyreferto continuous occupancy ofnot more thanthirty(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 dweliing unit shail not be considered transient.Occupancy that is subject to the coliection 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 Departrnent to schedule the inspection three{3)days prior to opening.PLEASE NOTE:People are NOT aliowed to srt 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 Department three(3)days prior to opening,and quarterly thereafter. POOL CI.OSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Deparlment 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 Hea1th Deparkment 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.usunderHealthDepartment,DownloadableForms. 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 revocatton of your Frozen Dessert Pe�mit until the above terms have beenmet. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),musthave prior approval from the Boa�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 Decembet 31. IT IS YOUR RESPQNSIBILiTY TO RETURN TI-�COMI'LET'ED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. ALL RENOVATIONS TO ANY FOOD ESTABLISHIvfENT, MOTEL OR POOL (i.e., PAIN'TING, NEW EQiJIPMENT, ETC.), MLJST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT.RENOVATIONS MAY REQUIRE A SITE PLAN. DAT'E:4/13/20U SIGNA'TURE: �� _� PR1NT Nt�Iv1E&TITLE:William Hunt,President Hunta,Inc. Rev. 10/12/16 � i , '`�c�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDD/YYYY) 04/13/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY 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 certi�cate holder is an ADDRIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. ff SUBROGATION IS WAIVED,subject to the terms and eonditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER C ACT NAME: DiBnna Tubenrilie �°"E : (205)262-2700 a No: (205)262-27Q1 Go S.S.Nesbitt&Company E,�� 3500 BIuQ Lake Dr.#120 ADDRESS: BlfRtl(19IlafTi,AL 35243 INSURER S AFFORDING COVERAGE NAIC# �NsurtERa:American Zu�ch Insurance Com n 40142 INSURED INSURER B: HR Service Group,LLC 3905 Nationat Dr_Suite 400 �NsuRErt C: Burtonsville,MD 20866 �NgurtER p• iNsuR�e• INSURER F: COYERAiGES CERTIFICATE NUMBER:16MD507938075 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 CONDITtON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFfORDED BY 7HE POLICIES DESCRIBED HER�IN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClA1MS. 'LTR T1(FE OF INSURANCE �DL SUBR p��Y NUMBER M p� MMfD Y� �� COMMERCWI,GENERALLIABIIITY EACHOCCURRENCE $ CLAIMS-MADE �OCCUR DAMA E TO RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&AOVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLiCY❑jE a �LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIA&LRY COMBINED SINGLE LIMIT $ Ea acciderd ANY AUTO . BODILY INJURY(Per peisan) $ OWNEO SCHEDULED AUT0.S ONLY AUTOS BpDILY INJURY(Per acxident) $ HIRED NON-OWNED PROPERTYOAMAGE $ AUTOS ONLY AUTOS ONLY Per acadent $ UMBRELLA UAB pCCUR EACH OCCURRENCE $ EXCESS lIA6 CIAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERSCOMPENSATION X PER OTH- AND EAAPLOYERS'LIA8ILITY y�N STATUTE ER A OF CE�R/M MB REXCLUDED?ECUTIVE ❑ N�A WC01��80-0� p4/73/2017 U5l01/2017 E.L.EACHACCIDENT $ �,QQQ,QQQ (Mandatary in NH) E.L.pISEASE-EA EMPLOYE $ �,�,�� If yes,�scribe under � DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 'I,OOO,OOO Location Coverage Perlod: 04l13/2017 05/01/2017 Cllentl! 0385-MA DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remerks Schedule,may be attaehed H more space is requi►sd) Hunta Inc dba:Beef Jerky OuUet �"�'��O��Of 525 Route 28 only thase co-empbyees �,but rat subcontradors West Yarmouth,MA 02673 to: CERTIFICATE HOLDER CANCELLATION Hunta Inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE dba:Beef Jerky Outlet THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN 525 ROUte 28 ACCORDANCE WITH THE POLICY PROVISIONS. West Yarmouih,MA 02673 AUTHORIZED REPRESENTATIVE ��G� O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(20161031 The ACORD name and loao are reaistered marks of ACORD