HomeMy WebLinkAboutApplication and WC ,
. 10/18/2016 XFINITY Cornec.�t Lig hdng New York-Quote Req uest(118'1964)Prir�out R�t+�'v L�
Y 18 2017
Towrt oF Yax�ouTx soaRn oF�.a►i.�rx HEALTH DEPT.
APPLICATION FOR LICENSEIPERMIT-2{!17
'Please complete form and attach all nec�}+documents by December 1 2016.
Failure to do�will result in the ret�rr►of your applicaLon pac cet
i ESTABLIS�R�IENT NAME: __. _._ �r.�
� LOCA7TON ADDRESS: TEL.#:
; ,��;�.,� ,�
, MAILING ADDRESS:
E-MAIL ADDRESS: ' 4
OWNER NAME• a,c. ;�?: �
CORPORATION NAME APPLICAB� �2 +� fcSO
MANAGER'S NAME: A � V D TEL.#: rSb cj �==s}.,
- MAILING ADDRESS:
POOL CERTIFICATION�:
The pool sapervisor mnat be certit�ed as a Peol Operator,as reqairsd by State lsw. Please tist the designated
Pool Opecator(s)and att�ch a cop�of the cerfification to tttis form.
1-���'SoaJ �I�sQU 1 !3a 2,
Pool opecators must list a minimum of two employaes c�urently certified in standard First Aid and Commimity
Cazdiopulmonary Res�iscitation(CPR�having o�ce�tified oyce on pretnises at all times. Please list the
employees below and attach copies of their cxatifications to t}vs�orm.The Health Deparim�t wili nat ase past
years'records. Yoa mast provide new copies nnd maintnin'Sle at yonr place of b�inesa
1. ��iUk'1'�G\► �nC� ��('U 2, ���1� ���1�
3. oJ u � 4.
FOOD PRO'FEGTiON MANAGERS-GERT7FICATIONS:
All food service establish�nts are required w have at least one full-time�ployee who is ceatified as a Food
Protection Maosge.r,as defined m the Stabe Sanitary Code for Food Setvice Fstabiishments,105 CMR 590.000.
Please attachcopies ofce�tifiarti�to tbis a�licatian.T6e H�De�eat wiII�t�e p�st years'records.
Yoa mast provide new copies sad nsiotx�a fik st yoar establisLm�t
1. Iv ri 2. ,
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation.
i. N � a.
ALLERGEN CERTIFICATTONS:
All food service establishments are roquired to have at le,ast one fiill-time employee who has Allergen oertification,
as defined in tl�e State Sanitary Code for Food Service Bstsblishm�►ts,105 CMR 590.009(Gx3xa). Piease attach
copies of c�tification to this appliccation. T6e Hea�h De�srtmest will not nse pnst yeara'records. Yoa mast
provide new copies aad msiatain a Sk at yonr eshbl�hment
1. � � 2.
HEIMLICH CFR"T�FI�A7'lQNS:
All food service establishme,nts with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on t�premises at all times. Piease list yo�semp loyee.s trained in anti-chokmg prncedures below a� ;
attach copies of employee certifications to this form. T6c Hc�t Deparlment vrill not ase past years'records. '
Yoa maet provide new eopies and mumtsin a fle at your place of bnsiness.
1. �� 2, ,
3. 4. '
RESTAURANT SEATING: TOTAL#
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LonGnvc:
OFFICE USE ONLY
L[CENSE REQU[RED FEE PERMIT i LICENSE RBQUIR6D FEE PERMIT M LI SE REQUIItED FEE P
� S55 CABIN s55 M01EL f110 �`�� (�
—'N1N SSS CAMP SSS �VDNbIING POOL S110ea����=Lyi-"�� �/'
_ �IADOE SSS . =TRAi[,ER PA1LK 5105 _�Vf�RL�OOL S110ea i�� J�t�� �f
`.� � �
FOOD SF.RVICE: � � ;
LICENSE FEE PF.RM17'!t LICENSER£QUIRgD FEE PERMIT# LICENSE �(}UIRED FEE PERMI'f# �
0-IOO SEA�'S�� 5125 _CONI1NENfAL. S35 NOT�PR0�1T S30
>I00 SEATS 5200 _COMMON VIC. S6� WHOLESALE SSO
RETAII.SERVICE:
=RESID.KITCHEN S80
LICENSE REQUIRF� FEE PERMlT# LICENSE REQUIREp FEE PggM1T# LICENSE REQI3IItED FEE PERMIT# i
GSOsq 8. S30 >25 000 R SZ85 YENDING-FOOD S25
_QS,000 sq.R SI50 �RaZEN�ESSERT f40 `'TOBACCO 5110
NAME CHANGE: SIS alyjOjJjlj j']j�i = s ?iZC�OQ
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ADMIIVISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now requirad to hold issuance or renewal
of any license or permit to opeiste a basiness if a person or company does not have a Certificate of Wo�lcer's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANG'E !
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 renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABI.ISHIVI�NTS
TRANS�IVT OCCUPANCY: For purposes of the limitations of Motel or Hotel ux,Transient occupancy shall be
limited to thc teraporery aad short tem�occupancy,ordinarily and c�tomarily agsociated with motel aad hotel use.
Transiern oixupants must have and be able to de�monsd�ate that they maintain a prin�cipal place of residence
elsewhere.Traosient occupancy shall generally refer to continuous ocxupancy ofnot more thanthicty(30j days,a�l
an aggregate of not more than ninety(90)days wiWin any six(6)month period. Use ofa guest unit as aresidence or !
dwelling imit shall n�t be consideaed�ansient. Occu�ncy that is subject to the collection of Room Oc�ncy . "'
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considered Transient.
POOI.S
POOL OPEIVII�TG:All swimmirig,wading and whirlpools which have baen closed for the season must be inspected
by the Health De�artment pnor to op�u�g Contact the Health Department to schedale tLe inspection three(3)
days prior to opening.PI.EASE NOTE:People are NOT allowed to sit in the pool area w�til the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tesoed for pseudomonas,total coliform and standm+i plate count ,
by� a�S�certified lab,and submitted to tl�Health Departmern three(3)days Priar tb ope�►ing,and quarberly .
POOL CLOSING:Every ouWoor 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�e Health Departmeat prior to openieg. Please contact the
Health D�t to schedule the inspection three(3)days prior to opening.
CATERWG POLICY: '
Anyone wl�caters within the Town of Yarmouth mast notify the Yarmouth Heatth I�partme�nt by filing khe .
reqwred Temporary Food Service AppGcation form 72 hours prior to the catered evern. These f�ms can be
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.us.under H�lth Departmern,
Downloadable Forms.
FROZEN DESSERTS:
Finaen desserts must be tested by a State certified lab prior to opening a�i monthly thereafter,with sample results
submitted to the Health Deparmient. Failuce w do so will result in the suspension or revocation of your Frozen
Dessert Pe�tqit u�l the above tesms have been m�t.
OUTSID�CAF�S:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior ap�mval&om the Board ofHealth.
; OUTDOOR COOI�NG:
i Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prebibited.
i
' NOTICE:P�mits nm annually from January 1 to December 31.TT LS YOUR RESPONSIBILiTY TO RETURN
; TFiE COMPLE�'ED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 16,2016. I
! '
' ALL RENOVAITONS TO ANY FOOD ESTABLISHIvV bI�NT, MOTEL OR POOL (i.e., PAIIVTING, NEW I
, EQUIPMEN'P,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR I
TO CO�NCEMENT. RENOVATIONS MAY REQUIItE A SITE PLAN. ' !
DATE: �� �� SIGNATURE: ,f2t� � !
PRINf NAME 8t TTfLE: { CY1� 'UW t�S�1�L� �'Q�r� �
T '�
� The Comnwnwealth ofMassachuseus
Departnunt of Indusb�ol Accidents
O,�ce of Investigat�ions
' I Congress Stree�Suite 100
Boston,MA 02114-2017. '
www mass.gov/dia
Workers' Compensation Insvrance A.f�davit: General Bnsinesses
Anulicant Information Please Print L�egiblv
BusinesslOrganization Name:���'��1V'� R- �r-J0�(L'�" l.�.-C--�
aaa�ss: � '�8 �c.�s�-� �� �� 62.�b
. __
- _ -- - _
City/State/Zip: 't�A� �' Phone#: ��S ��1 S 2g�3Q
Are yon employer?CLeck t�e.appropriste boa: Business Type(reqnired):
1. I am a employer with_�employees(full and/ 5. ❑Retail
or part-titne).* 6. ❑RestaurantJ'Bar/Eating Establishment
2•❑ I am a sole proprietor or partnelship and ha.ve no �, �p���a/or Sales(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. ❑Entertainniern
their right of exemption per a 152,§1(4�and we have 1 p.����ng
no employees.[No workars'comp.insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.[]Health Care
with no employ�s. [No workers'comp.insurance req.] 12.[�Other �C�Y1"��
'MY epplicaot d�at cleecks bax#1 must also 8ll oirt fhe s�ion belowa�wing the�worloers'�rian Polic3'u►fonnffiion•
ssIf the corpo�e offioeis have exempted the�elves,Mrt the oapaffiioa ha4�her e�MY�a�$'�P��9 is s�ired�d soch�
osga�tio�n shoWd c�Ck baoc#L
_ .
I am au employer tlkat is,ptovidi�g wurkers'co�pensado�inwirwtce for my e�r�p[oyeeS Below is tlie polky i�ejorm�o�. __
Insurance Company Name: �
Ins�rer's Address:
CitylStatelZip:
Policy#or Self-ins.Lic.# Expirartion Date:
Attsch a o�py of the workers'oompe�aatioa poliry decliration�e(showing the policy►anmber and ezpirat�oi datte). �
Failure to secure coveTage as required under Section 25A of MGL c. 152 can lead to the innposition of criminal penalties o€a
&ne up to$1,500.00 a�l/ar one-year imprisonment,as well as civil pe,�alties in the form of a STOP WORK ORDER and a fine ;
of up to 5250.W a day against the violator. Be advised that a copy of this st�xn�t may be forwarded to the Office of
Investigatians of tbe DIA for insurance coverage verification. '
I do hercby ' kRdcr tbe pa�nc aad parelties ojper�ttry tkat tbe�for�on prov�ded abr►vie is�n�e and c�nrnec� '
Q���l�' �o l �1 `tv �
#• �O ��� �p
OA9cial Wse only. Do iwt write in this erea,to lx con�plated by city or town o,J�''rciaL
City or Town• p����#
Issaing Aat6ority(circle one): i
1.Board of Health 2.Bnildiag Departme�t 3.CityfTowa Cterk 4.Licensing Board S.Selectmea's Office
6.Other
Contact Person:__ Phone#: .
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/^� LEWIBAY-01 A
'4�R�m CERTIFICATE OF LIABILITY INSURANCE °�'�'""°"'°°""�"'
05/18J2017
THIS CERTiFICATf IS ISSUED AS A MATTER OF INFORMA710N ON�Y AND CONFERS NO RIGHTS UPON THE CERTiFlCATE HOWER THIS
EERTIfiCAI'E DOES NQT AFFlRMATfVEtY UR NEGA7tYELY kMENE?, EX'FENtT OR ktTER 71tE COVERRGE AFFORDEQ BY THE POtICiES
BELOW. THIS GERTtFlCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETNtEEN THE ISSUING INSURER{S),AUTHQRIZED :
R€PRES�NTATIVE O!t PRODUCE�,AAI�TH€CERTiFlCATE HOLDER,
IMPORTANT: If the certifica�e holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITiONAL INSURED provisia�s�be endorsed.
ff SUBROGATtO�t IS WARfE�, subje�t to tAe terms a�sd�wsditions�tt►e i�i'�r,certain poTicies may require an errdo�seme�rt. Ik stater�nt on
tl�is certifiicabs does not corrter ' hffi Eo the certificabe holder in lieu of such s.
aRonuceR �T
Ro�ers d��uay lnsaran�Agency,lnc. �rwr� Fax
a34 i�e�t3a �.�r• c�vc,r�o:(Sn)s16-2156
south Denr�,MI►o2sso .mai rs .can
urSu s/�FO1tBlt�6 covE�taGE wn�c#
�Ng�ttERa:Norfolk&Dedham Mutual Fire IRsurance Comparryr 23965
� fNSURER B:
Lew�s Bay Properties,ine. u+su�re c:
8 Parker's River Resort,LtE
P.O.BoX 753 nasur�R D:
YYest Yarmartfi,MA 02673 iNgUr�E:
INSURER F•
COYER/iGES CERTI�ICAT�NUM�ER: R�1/ISIOM MUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIdD
INUiCATED. NOTWtTHSTANDfN6 A#Y REQ�FREMENF, TERM OR CONDITION OF RNY CONTRAC�OR Ol}tER DOC#1MENT 1MTH RESPEC��O WHICH SFitS
CERTIFICATE MAY BE ISSUED OR MAY PERTAlN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLU$IONS AND CONDITIONS OF SUCH_POLIC(ES.LIMtTS SHOWM NIAY HAVE BEEN REDUCED BY PAfD CLAIMS.
__ _
- -- _ __ __ _ _ _---
�� TYPE OF INSURANCE POLICY NUMBER POIICY EFF POtJCY EXP UMITS
�'��� EACH OCCURRENCE $
CLAIMS-MADE �OCCUR DANIAGE TO RENTED
S
MED IXP one $
PERSONAL 8 ADV INJURY S '
GEML AGGREGATE!lMIT APPLIES PER: GENERAL AGGREGATE S
PR
POLIGY �� !OC PRODUCTS=COMPlOP kGG S
OTHER:
AUT�.E LU1B�(IY COMBINED SINGLE LIMCf
' en
ANY AUTO
OVIMED SCHEDULED 80DILY INJURY Fer
AUTOS ONLY AUTOS BODILY INJURY Per aoddent �
�AUTOS OI�Y AUFOS ONLY P����� �5 ;
a
UMBREI.LA W1B OCCUR EACH OCCURRENCE S
IXCESS 11A8 CLAIMS�MADE AGGREGATE $
D€D RETENTION t
A wowc�Rs c�o�sa�na+ �R orri-
aw��.ov�•[.u►e�m 114835A 05l18/2017 05118/2018
ANY PROPRIETORIPARTNERtEXECUTR/E Y�N E.L.EACH ACCIDENT $ ���
EWME�EXCLUDED? ❑N N/A ��
in E.L DISEASE-EA EMPLOYE S '
rc yes,aescxibe�rW�
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ �����
D�PTION��ERRTiO1�IS/COCATWNS 1 YEHCL.ES(ACdiD tOt.Ad�Onal Remarl[s Sd�edWe,�y be aaacheA B nl0ie SQace�requilpd�
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOYE DESCRIBED POLICIES BE CANCELLED BEFORE
TOWN OF YARMOUTH THE �w�rrnTror� unTE Tr�xEo�, r�oT�cE w� e� o�u�RED IN '
1146 ROUTE 28 accORDaNGE YV1TH 7HE POLICY PROV1310N3.
SOUTH YARMOUTH,MA 02664
AUTF�Ep REpRESENTATNE
�jN7ll� �I����.� .
ACORD 25(2016/D3) �1988-2015 ACORD CORPORATION. AB rights raserved,
The ACORD�ame and logo are registered marks of ACORD '
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