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Home My WebLink AboutApplication and WC � � � G�/i� � 2 i � � �� y TOWN OF YARMOUTH BOARD OF HEALTH ; � � APPLICATION FOR LICENSE/PERMIT -2017 �'�`' �i � �(�j� ; i "`°' * Please complete form and attach all necessary documents by De m Failure to do so will result in the return of your application . T ESTABLISHMENT NAME: �P 'C TAX ID• --' � � LOCATION ADDRESS: �IL � TEL.#: � � MAILING ADDRESS: V r' l/ ' � E-MAIL ADDRESS: I OWNER NAME: ' r- 1+/ CORPORATION NA E (IF APPLICABLE): . , MANAGER'S NAME: Pi� I�✓ TEL.#: � � — - �� i; MAILING ADDRESS: r'� 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.� (' ��1 �✓�� f Sj 2. 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 certifications to this form. The Health Department will not use past years' records. You must provide new copies and mai ain a file at your place of bu iness. l_ p f��`� `�' �,/ 2. i 3. 4. � � I FOOD PROTECTION MANAGERS - CERTIFICATIONS: t 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 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. 1. ' 2. PERSON IN CHARGE: ' Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2. � I ALLERGEN CERTIFICATIONS: j 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 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 �le at your establishment. � 1. 2. i 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 pastyears' records. You must provide new copies and maintain a file at your place of business. i 1. 2. . 3. 4. RESTAURANT SEATING: TOTAL # OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ICENSE REQUIRED FEE P RMIT# B&B $55 CABIN $55 � MOTEL $110 INN $55 CAMP $55 SSWIMMING POOL$110e . _LODGE $55 _TRAILER PARK $105 =WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 � _COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RE'I�,IL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 ' � _<25,000 sq.ft. $150 =FROZEN DESSBRT $40 _TOBACCO $110 � i NAiyfE CHANGE: $15 AMOUNT DUE _ $ Z.ZO�� I � i *****PLE.ASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ' � � ! � � - y- ADMINISTRATION � Urider Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or re�ewal of a�y license or permit to operate a business if a person or company does not have a Certificate of Worker's Gompensation° Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT 1kIUST BE COMPLETED AND SIGNED, OR � CERT. OF 1NSURANCE ATTACHED OR � WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces 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 place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirly(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 0=ccupancy 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 area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total colifonn 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: 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, 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 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 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. IT IS YOUR RESPONSIBILITY TO RETLTRN 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 EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQtiIRE A SITE PLAN. ; DATE: SIGNATURE: \ PRINT NAME& TITLE: ' Rev. 10/12/16 . ' � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' ' ' 1 Congress Street, Suite I00 - Boston, MA 021I4-2017 � www.mass.gov/dia ; Workers' Compensation Insurance Affidavit: General Businesses ' i A licant Information Please Print Le ibl ; �i � Business/Organization Name: ��,s � �� I , Address: �� - 5�� S�� . � � � � � �� City/State/Zip: �d� � � � Phone #: � �� () ' Are y an employer?Check th appropriate box: Business Type(required): 1`. I am a employer with employees(full and/ 5. ❑ Retail � or part-hme).* 6. ❑ RestaurantlBar/Eating Establishment � 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] g• ❑ 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.❑ alth C e 4.❑ We are a non-profit organization, staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12 Other *Any applicant that checks box#1 must also fill out the section below showing theu workers'compensation policy information. **If the corporate officers have exempted themselves,but the corpora6on has other employees,a workers'compensation policy is required and such an I organization should check box#1. I am an employer that isproviding workers'compensation insur nce for my em yees. Below is thepolic information Insurance Company Name: �'S�j O�/0��'� �P�V ��P�''S (v�/G�/lJ� -- �r M, �"��,� !�. � �_'J / Insurer's Address: ��'n 2„ ��('/�� ,r�C,/`� T� �'f'�� City/State/Zip: Policy#or Self-ins.Lic. # l � Expiration Date: � � Attach a copy of the workers' compensation polic decla tion page(showing the policy number and egpiration 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce ify,und t ains and penalties of perjury that the information provided above is true and correct. S i ature C/J� Date: Phone#: Officia[use only. Do not write in this area,to be compteted by city or town officia� 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#• wwwmass.gov/dia d '�� • CtJMMERCIAL INSURANCE APPLICATION oA��MroorvrYY� ACORO � APPLICANT INFORMATION SECTION o�n�no�� pG�ryCy CARRIER �'�'°`��a� Dowling&O'Neil Insurance qg Associated Employers Insurance Company 11104 873 lyannough Rd,PO Box 1990 COMPANY POLICY OR PROGRAM NAME PR06RAM COdE ( Hyannis MA OZ601- POLICY NUMBER . � APP436463 f CONTACT C81tIlf1 R@J8� � UNOERWRRER UNDERWRITEROFFICE i PHONE , 508 775 1620 Fax �pa��g 1Z1g �UOTE ISSUE POLICY RENEW ! E'�'�A�� cre en dans.cam STATUS OF BOUND(Give Dffie andlorA2[ach CopyJ: � AD ss: 9 @ �,arisncnori CODE: SUBCODE: 100 CHANGE DATE TIME p� AGBdCYCUSTOMERID: z�CSHO CANCEL PM � SECTIONS ATTACHED I�DIGATE 9EGTIpNS ATfACHED PREMIUM PREMIUM PREMIUM � ACCOUNTS RECEIVABLE! ( R 5 ELECTRONIC DATA PROC S � PROPERTY t ; BOILER&MACHINERY S EQUIPMENT FLOATER = TRANSPORTATION/ : i i BUSINESS AUTO S FIDUCIARY LIABILITY COVERAGE t TRUCKERS/MOTOR CARRIER 5 � BUSINESS OVNVERS S GARAGE AND DEALERS S UMBRELLA 1 � i COMMERCIAL GENERAL LIABILITY S GLASS AND SIGN i YACHT t � CRIME S INSTALLATIONlBUILDERSRISK s WorkersCompensetion 1 i CYBER AND PRIVACY COVERAGE S LIOUOR LIABILITY = S j DEALERS S OPEN CARGO S S I ATTACHMENTS ' ADDITIONAL INTEREST INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT j ADDITIONAL PREMISES LOSS SUMMARY � 4 APARTMENT BUILDING SUPPLEMENT PREMIUM PAYMENT SUPPLEMENT � CONDO ASSN BYLAVvS(for D&0 Coverege only) PROFESSIONAL LIABILITY SUPPLEMENT CONTRACTORS SUPPL EMENT RESTAURANT!TAVER N SUPPLEMENT i COVERAGES SCHEDULE STATEMENT/SCHEDULE OF VALUES I DRIVER INFORMATION SCHEDULE STATE SUPPLEMENT(If applicable) � � I HOTEL/MOTEL SUPPLEMENT VACANT BUILDING SUPPLEMENT � INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VEHIC�E SCHEDULE � POLICY INFORMATION PRpPOSEQ EFF DATE PR6POSE0 EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYNIENT AUDIT DEPOSIT p�MIUM Pa�ICY PREMIUM �7�'��0�� 07/11l2018 DIRECT AGENCY ; ; ; i APPLICANT INFORMATiON � NAME(First Named Imursd)AND MAILINCa ADDRESS pncluding ZIP+4) GL CODE SIC PIAICB fEIN OR 90C 8EC t � JCS Hospitality, LLC � C/O JeTfrey C S�vartr susn�ss PHor�c (508)3646700 ! 192 South Shore Drive +�ssi�noo�ss ' South Yarmouth MA 02664 j CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS ppRTNERSHIP TRUST AND MANAGERS: . NAME{Oth�r N�m�d Insurs�AND MAILIN6 ADDRESS Qneludinp ZIP►4) GL COOE SIC NAICS FEIN OR SOC SEC t BUSI�SS PHONE k ' WEBSITE ADDRE33 CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION , INDIVIDUAL LLC NO OF MEMBERS pp,RTNERSHIP � TRUST � AND MANAGERS: NAME(Qther Namsd Insun�AND MAILING ADORE33 pnetu�np ZIP+4) GL COOE SIC NAICS FEIN OR SOC SEC f BUSINESS PHONE i: i i WEBSIlE ADDRESS � CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS p,4RTNERSHIP TRUST � AND MANAGERS: ACORD 125(2014112) Page 1 of 4 O 1993-2014 ACORD CORPORATION. All rigMa reeerved. The ACORD name and logo are registered marks of ACORD CDR AGENCY CUSTOMER ID: 2JCSH0 CONTACT INFORMATION corurncr�vPe: Inspection Contact cornacrTvre: Accounting Contact corrracr ru�: �effrey C Swartz corrrncr ran�: �effrey C Swartz PHONER% ❑HOME�8US ❑CELL PH�E+� ❑HOME 0 BUS ❑CELL pHONE/ ❑�ME❑BUS ❑CELL pHONE A ❑HOME[]BUS ❑CELL � (508)364-6100 (508)3646100 PRIMARY E-MAIL ADORESS: Je1f2714�8d.COlY1 PRIMARY E-MAIL ADDRES3: Ieff2714�8d.COI11 SECONDARY E�h1AIL ADDRESS: SECONOARY E�►A0.A�DRESS: PREMISES INFORMATION Attach ACORD 823 for Additional Premises LOC# STREET 192 South Shore Drive CITY LIMRS INTERE5T �F FULL TIME EMPL APRJUAL REVENUES:: � INSIDE OWNER OCCUPIED AREA: SQ FT � BLD t cirr: South Yarmouth srn�: MA OUTSIDE TENANT *PART TIME EMPL OPEN TO PUBLIC AREA: S�FT : 1 counRv: Barnstable ZIpd2664 TOTAL 6UILDINGAREA: S�FT �ESCRIPTION OF OPERATIONS: S@850�181 MO�CI ANY AREA LEASED TO dTHER84 Y!N � LOC i STREET CITY LIM�TS INTEREST f FULL TIME EMPI ANNUAL REVENUES:{ INSIDE OWNER OCCUPIED AREA: SO FT I @I,p# CITY: STATE: OUTSIDE TENANT •PART T1ME EMPL OPEN TO PUBLIC AREA: SQ Ff � i COUNTY: ZIP: � TOTAL BU�L�ING AREA: S�FT DE9CRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y!N LOC• STREET CITY LIMITS INTEREST #FULL T1ME EMPL ANNUAL REVENUEB:; INSIDE OWNER OCCUGIE�AREA: SQ Ff I BLD f CITY: 3TATE: OUTSIDE TENANT •PARTTIME EMPL OPEN TO PUBLiC AREA: S�Ff COUNTY: ZIP: TOTAL BUILDING AREA: Sa FT OESCRIPTION OF OPERATION3: ANY AREA LEASED TO OTNER89 V 1 N . LOC t STREET CITY LIMRS INTERE3T •FULL TIME EMPL ANNUAL REVENUES:; INSIDE OVVNER OCCUPIED AREA: S�FT BLD# CITY: STATE: OUTSIDE TENANT �PART TIME EMPL OPEN TO PUBLIC AREA: S�FT COUNTY: ZIP: TOTAL BUILDING AREA: SQ FT � QESCRiPTION OF OPERATION8: ANY AREA LEASED TO OTHERS?Y/N ! NATURE OF BUSINESS � APARTMENTS CONTRACTOR MANUFACTURMG RESTAURANT SERVICE BTART�J(MMIODIYYYY) f CONDOMINIUMS INSTITUTIONAL OFFICE. RETAIL 4NiOLESALE � O7ro5nd�7 I DESCRIPTION OF PRIMARY OPERAT10N3 � Seasonal Makel P , I f { � INSTALLA710N,SERVICE OR REPAIR WORK OFF PRENpSEB INSTALLATION,8ERVICE OR REPAIR WORK RETAIL STORES OR SERVICE OPERATIONS%OF TOTAL SAIES: 96 � °� � DESCRIPTION OF OPERATIONS OF OlHgt NAMED INSUREDS ' � i � � ADDITIONAL INTERE8T Not all fields a I to all scenarios- rovide onl the necessa data Attach ACORD 46 for more Additional Interesta INTEREST NAME AND ADDRE33 RANt: EVIDENCE: CERTIFICATE POLICY SEND BILL INfERE3T IN ITBri NUMBER ADUITipNAI �pS3 PAYEE LOCATION: BUtt.DING: INSURED BREACH Qf MORTGAG� VEHICLE: BOAT. WARRANT`! ' GQ�QWNER OMfNER AIRPORT: AIRCRAFT: '' ... EMPl.OYEE REGISTRAM � � CLAS3: ITHrt: ASLESSOR ' IEASEBACK ��s� ITBA DESCRIPTION OWNER LIBJHOLDER REFERENCE t LDAN�: IMEREST END DATE: LI9J AMOUNT: PHONE(AIC,No,Exq: FAX(AIC,No): REA�N FpR INTEREST: E-MAIL ADDRESS: ACORD 128(2014112) Page 2 of 4 CDR