The URL can be used to link to this page

Home My WebLink AboutApplication and WC, �� TOWN OF YARMOUTH BOARD OF HEALTH APPLI�ATION FOR LICENSElPERMIT-2018 *Please complete form and attach all necessary documents by December 1 S 2017. Failure to do so will result in the return of your applicat�on pac cet. ESTABLIS1iMENT NAME: 1 • - LOCATION ADDRESS: i ti TEL.#: - �`j3,�� MAILING ADDRESS: E-MAIL ADDRESS: � OWNER NAME: � +- CORPORATION NAME(IF APP�,ICt1B�E): S MANAGER'S NAME: TEL.#• 3lJr�/ �� MAILING ADDRESS: CG �O 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- 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community � � '�' Gardiopuimonary Resuscitation(CPR), having one certified employee on premises at all times. Please list the b -n-i �T� employees below and attach copies of their certifications to this form.The Health Department will not use past � N C��i years'records. You must provide new capies aad maintain a file at your place of business. = w �'1 1. 2. � rv '� 3. 4. :-I o �7 FOOD PROTECTION MANAGERS;CER'TIFICATIOI�TS: 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�tate Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certificarion to t�iis application. The Health Department will not use past years'records. ,._, You must provide new copies and maintain a file at your establishmen� � �.�•�-j ��/+2 D�.�o 2. � �ri D,�tL— �� PERSON IN CHARGE: ' ''� Each food establishment must have at least one Person In Charge(PIC}on site durin hours of o�eration. 1.�/tZ/f ��/4-iC�/�(1 ; 2. �� /iu� � 3 ti»,;,� ALLERGEN CER'I'IFICATIONS: � �; All faod service establishments are required to have at least one fiill-time employee who has Allergen certification, �;�,"" ` :� as defined in the State Sanitary Code fdr Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this applicarion. The Health Department wilt not use past years'records. You must provide new copies and maintain a file at your establishmen� , i. �i�Nl ��2_,%iiv� a.�d ��i20/.�� . HEIMI.ICH CERTIFICATIONS: � All food sexvice 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-choldng pmcedures below aod attach copies of employee certifcations to this form. The Hexlth Deparlment will not use past years'records. You mast provide new copies�nd ntaintaia a file at your place af business. 1,�� /��tia 2. � lT/f��/s✓�J 3. 4. RESTAURANT SEATING: TOTAL i� � f1 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMC£# LICENSE REQUIRED FEE PERMIT# B&B $55 CAB1N $55 MOTEL �I10 LO1�GE $55 C� $55 _SWA9�IING pppL$110ea. _CRAII.ERPARK $lOS WHIItI,PaOL $li0ea. FOOD SERVICE: LICENSE UIRED FEE PERMIT# !LICENSE REQUIRED FEE PERMIT# LICENSE REQ UIRED FEE PERMI'I'# 0-IOO SEA 5125 � ; CONTINENTAI, �35 NON-PRO�'11' $30 �1r� �>100 SEATS $200 � �COMMON VIC. $6(t �3 �{rgOLESALE $80 �rr r��-b�s RETAIL SERVICE: —RESID.KiTCHEN$8p � LICENSE REQUIRED FEE PERMtl'# ;LICENSE REQUIRED FEE PERMIT#. LICENSE �� _�SOsq ft. S50 : >25,f�10sq.R 5285 VENDING FOOD � PERMIT# _C2S,OOOsq.ft $l50 =F'ROZENDES5ER'��40 i1'OBA(�Q $li0 lYAME CHANGE: St5 1�M1�jJN1'D� _ $ .'�Dd.�� °***•PLEASE TURN OVER AND COMPI,ETE OTHEK SIDE OF FORM**xt* ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town af Yannouth is now required to hold issuance or renewat 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 A'ITACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLE'TiED AND STGNED,OR CERT.OF INSURANCE ATTACHED � OR WORKER'S COA�IP.AFFIDAVIT SIGNED AND AITACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your perniits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LOD�ING ESTABLISIIlVIENTS TRANSIENT OCCtTI'ANCY: For purposes of the limitations of Motel or Hotei 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 b� able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30}days,and an aggregate of not more than ninety(9q)days within any six(6}month periad. Use of a guest unit as a residence or . dwelling unit shall not be considered itansient. 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 Trausient. ; POaLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspc,�cted by the Health Department prior to operimg. Contact the Fiealth Department to schedule the inspection three(3) days prior to opening.PLEASE NC)TE:People are NOT allowed to sit in the poot area until the pool has been inspected and opened. POOL WATER TESTING: fihe waCer must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted�to the Health De�artment three(3)days prior to opening, and quarterly thereafter. POOL CLOSYNG:Evezy outdoor in�ound swimming pool must be drained or covered within seven{7)days of closing. FOOD SERVICE SEASONAL FOOD SERYICE OPENING: ,All food service establishments must be inspected by the HeaJth Department prior to opening. Please contact the Health Deparhnent to schedule the inspection three(3)days prior to opening. CATERING POLICY: Anyone who caters within the Town af Yarmouth must notify the Yarmouth Health Department by filing the required Temiporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Heatth Department,or finm the Town's website at www.yarmouth,ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Fmzen desserts must be fested by a Sta�e certified lab prior to opening and monthly thereafter,with sample results submitted to the Heal#h Department. F'aiiure to do so will xresult in the suspension or revocation of your Frozen Dessert Permit until the above terms ha�e been met OIJTSIDE CAFES: Outside cafes(i.e.,outdoor seating witli waiter/waitress service),must ha�e prior approval from the Boar+d of Heaitii. OUTDOOR COOKING: Outdoor cooking,prepazation,or display of any food product by a ratail or food service establishmerrt is prohibited. NOTICE:Permits nui annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APP�,ICATION(S)AND REQLTIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIflNS TO ANY FOi(JD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIN'TING, NEW EQUIPMENT,ETC.),MUST BE REPbRTED TO AND APPROVED BY TI�BOARD OF HEALTH P TO COMMENCEMENT. RETTOVATIONS MAY RE UIRE A SITE PL DATE: �� — SIGNATURE: , P12INZ'I�tAME&1'ITLE: /=l�I d�L�/�--.�' (�!/�l�.D/N�,__� �.ronvc7 �5!f�P„TT' , C�ARDIN4'S 242 Main Street,Route.28 WestYarmouth,MA 02673 b,�--�`-�J �?�"a � / N C�A�t G�. /� -�� -/ � --_— — - ��z-. a D/c� � , �D / � � �/2CJ�No �� "l �/ �►-7 �-l�/�v Z� � �� oi� a �� o G� � �� y L /�/r �� e��- � �d � �q- , � The Commonwealth of Massachusetts Print Farm � = Department of Industrial Accidents �� Offce of Investigations � 1 Congress Street,Suite 100 • Boston,MA 02114-2017 ,� _.�'� ��-�' www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: V'!�-/Z �i �� Address: pC y� �" �'� /�7; � City/State/Zip: � /t m �`��h?�e#: ��- / ��-- � Are y�employer?Check the appropriate ox: Business Type(required): 1. I am a employer with�employees(full and/ 5. ❑Retail or part-time).* 6. staurantBarlEating 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] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per a 152,§1(4),and we have 10.� Manufacturing no employees. [No warkers' comp. insurance required]* 1l.❑ Health Care 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#i must also fili out the section below showing their workers'compensation policy informaiion. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Belo��s thepolicy info�'on. Insurance Company Name: 1J �f ---— � � ��f(l�iV C ti�, Insurer's Address:_ � Q, � �� City/State/Zip: !��V rC� N Q � � �- � �9 � � p e Policy#or Self-ins.Lic.# ( 1. t� � � / Ex irarion Date: � Attach a copy of the workers'compensation policy declaration page(showing the policy number and piration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to khe 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•tify,under the pains andpenalties ofperjury that t 'nformation provided above is true and correc� 0 Si ature: Date: – � Phone#: � � �^ / �S — Q� � Official use only. Do not write in this area,to be completed by city or town o�ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Healt6 2.Building Department 3.CitylTown Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#• www.mass.gov/dia A � Worker's Comgensation and Emuloyer's Liabilitv Policy �Wi Berksh i re Hathaway NorGUARD Insurance Company - A Stock Co. �/t Policy Number GIWC890772 '�p� Com anies Renewal of GIWC724890 , G U A R D p NCCI No. 2 [ 5844] Policy Information Page [1]Named Insured and Mailing Address Agency Giardino's Tastee Tower Inc. DGP-MILES INSURANCE AGENCY, INC. 242 Main Street PO BOX 1018 Yarmouth, MA 02673 Taunton, MA 02780 Agency Code: MAIROQIO Federal Employer's ID Insured is Corporation I � [2] Policy Period From September 1, 2017 to September 1, 2018, 12:01 AM, standard time at the insured's mailing address. I3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease - each employee $100 000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: � See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium � 2,627 Total Surcharges/Assessments � 101.00 Total Estimated Cost 2,728.00 INTERNAL USE xx Page - 1 - MGA : GIWC890772 Information Page Date : 07/28/2017 WC OOOOOlA MANOTE Issuing Office: P.O. Box A-H, 16 S. River Street, Wilkes-Barre, PA 18703-0020 �www,guard.com �'1 GIARD-1 OP ID:SV '`�� CERTIFICATE OF LIABILITY INSURANCE °"'�`"� 06/07/Z077 THIS CERTIFICATE IS ISSUED AS A MATTER OF INWRYATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFlCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY A�IEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIqES BELOW. THtS CERTiFICATE OF INSURANCE DOES NOT CONSTiME A CONTRACT BETYYEEN THE ISSUING INSURER(S� AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFlCATE HOLDER IMPORTANT: If the t�ertl8caes hoWer is an ADDiTIONAL INSUF�D,the Pu�c�rliesj must be endorsed. if SUBROGATION IS WAIVED,subject to the tem�s and condkans of the policy,certain polkies ma�r�e4uire an endorsement. A stalsrr�ent on t6is certificabe does rwt confer rights to the oertificats holder in Neu of such end s. �OD� ,�: Gordon G.Asack DGP-Miles Insurance Agency,inc 3 School Street P.O.Box 1018 PNONE 508$24-8961 F^x�,�,:508-880-2734 TaurMon,MA 02780-0957 e�uu� Gordon G.Asack AD°�° wst�s►n�rrc c�w►t� wuc s �n:Harleysville Insurance Co. �Nsur�u Giardino's Tasbee Tower Inc �B,Guard Insurance Group Eddie Giar+dino 242 Main St ��= West Yarmouth,MA 02673 w�e n: MISIIR�E: NSUI�t F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE IISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVNTHSTANDING ANY REQUIREMENT,TERM OR CONDI770N OF ANY CONTRACT OR OTHER D�UMENT V1flTH RESPECT TO WHICH THIS CERTIFICATE NL4Y BE ISSUED OR AitAY PERTAIN, THE INSURANCE AFFORDED BY THE POL�IE3 DESCRIBED HEREIN IS SUB.iECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS. lTR TYPE OF MISURANCE POLIC1f M1MBH2 POLICY EFF POI.ICY E7� �� GFJ�IHtAL LU18t.ITY EACH OCCURRENCE S ��s A X c��RClni.c�NEr�une�urr L37495W 08I�01/2017 081�01/2018 ��ses ea ocar�enoe s ��r CLAIMSMADE ❑X OCCUR MED EXP(MY�P�) E 5r �Rsow��s arnr iw.xxiv a �,�. GENERALAGGREGATE s 2,000, GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPfOP AGG i 2r��r X ppLICY �a LOC S AUTOMOBILE W►&UTY BI_N�ED SINGLE LIMR � ANY AUTO BODILY 1 WURY(Per peraon) S ��D ��D BOqLY1WURY(Pera�) E HIREDAUTOS �ED AUTOS PER A(xIDE� i i X urer�s.w una X occuri EACH OCCURRENCE a 1.000. q oa�ss uae Ct�uMs-MnoE 834586YY 08la1/T017 081�01/2018 nGCR�a� s 1.000. oeo X R�r�nor�s 10,000 Pers/Adv. a 1,000, �� Y J N �( wC STATLL TF4 B aav�oPRierorr�nRrN�cEcvrn� IYYC�80772 09/01/Z017 091�01/2018 E.L EACH ACCIDENT f 100, OFFICERIMBiAABER IXCLUDED9 � N!A ��) E.L DISEASE-EA EN�LOYE i ��r IFy��desuibe untler DESCRIPTION OF OPERATIONS below E.L DlSEASE-POUCY UMIT i �r A Liq�r Liability L314852 08p1fZM7 08/01/Z018 Occurrenc 1,000, A99� 2.�. DES(xtlPilON OF OPERATIONS/LOCATIONS/Y911CLFS(Atfxh ACORD 101.Ad6tioml�Schadde,if mas spaoe is requircd) Cov�erage8 are subject to the a�tusl policy teas, oonditi�s, li.=itatioaiS, definitions, endorseaents and eaclusions. CERTIFICATE HOLDER CANCELLATION swouw aNr oF�Aeov�oEscraem PouaEs ee cnNCEuee s�or� Town of Yarmoufh � �� a''� T►��. � �v- � ��ED �N 7146 Rt 28 A�►�E vnTM TME�ou�Y�. South Yarmoutfi,MA 02664 AUTFIORQED REPRFSENTATIVE �� ` � 01988-2010 ACORD CORPORATION. AII rights reserved. ACORD 25(2p10/05) The ACORD n�ne and Iogo are registered marks of ACORD