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Home My WebLink AboutApplication and WC TOWN bF YARMOUTH BOARD OF HEALTH APPLIGATION FOR LICENSE/PERMTI'-2018 '�Please complete form and attach ail n�essary documents by Decem er IS 2017. Failure to do so will resutt in?the retum of your application pac et. ESTABLISHMENT NAME: �' ► �'�— / LOCATION ADDRESS: a'&' ; TEL.#: v,S-� MAILING ADDRESS: � E-MAILADDRESS: / �l�//4�- A�Cj�`�""l OWNER NAME: �i�C �°"1 N��4� � CORPORATION NAME(IF APPLICt1BLE): ' MANAGER'S NAN1E: `�'8M Ntelct�-- TEL.#:f0�'S"t�.'�35� _ :� � MAII.ING ADDRFSS: � � � POOL CERTTFICATIONS: � The pool supervisor must be cerbified as a Pool Operatior,as required by State law. Please iist the designated = � � Pool Operator(s}and attach a copy of the certification to tlus form. m '� � , � � � 1. 2. '-I �,+ {� Pool operators must list a minimum of two employces ciurently certified in standard First Aid and Community Cardiopulmonary Resnscitation(CPR),having one cerEified employee on premises at all times. Please list the employces below and attach copies of.�eir cerkifications to tius form.The Health Department will not use past years'records. Yoa must provide new copies and maintain a file at yoar place of bnsinesa. ;�Y',.` L 2. 3. �F. e FOOD PROTECTION MANAGERS-CER'TIFICATIONS: All food service establishments are required to have at least one full-time employee who is certifi�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'r�ords. You must rovide new co ies and maintxin a file s�t �nr establishment. "' ,. � 1. ��°'1 /''�l,'-�le��v y 2. %_��i►" �tltr�`'�, � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operafion. l. �'�°s�f ,/��,c�� 2 �t�laC/t ,�`lL/�L/�i��i ,ALLERGEN CER'I'IFIGATIONS: All food service establishments are required to have at leagt one full-time employee who has Allergen certification; as defined in the State Sanitary Code fdr Food Service Es#ablishments,105 CMR 590,009(G)(3}(a). Please attach copies of cextification to ttris applicatia�n. The Health Department will not use past ye.ars'recorda. You mnst provide new copies and maintain a file at your establiehmenw l. ✓�'t ��G.11��il.[-'�� 2, HEIMLICH CERTIFICATIONS: All food service establishinents with 25 seats or more znust have at least one employee trained in the Heimlich Maneuver on the gremises at a11 times.' Please list your eomployees trained in anti-choking procedures below and attach copies of employee certifications to tbis form. TLe Health Department will not nse past years'records. You must provide new copi�and maintain a fite at ybnr place of bnsiness. 1. �/' yl A/r.t.t�ia�� 2 ��9U+,t�,s(�i.t-�'t�` � 3. `��`�"��i��atl�/�r, 4. RESTAURANT SEATING: TOTAL# '�� t,oncn+tc: OFFICE USE ONLY � LICENSE REQUIRfiD FEE PERMIT# LICENSE REQU3REIY FSE PERMIT# LICENSE REQUIRED FEE PERMIT,# B&B S55 CABIN SSS _MOTEL $!10 `—INN $55 GAMP ' SSS _SWtMIr1ING POOL$1 l0ea � LODGE SSS ='IRAILER PARK 5105 R+HTRL.POOL S110ea. FOODSERVICE: � �d�'F�IS`O� {O LICENSE REQUIItED FEE p�I�1T# LICENSE REQUIREU FEE PERMIT# LICENSE REQUIltED FEE PERMiT# �0-iQ0 SEA1'S 5125 tf't S�O F( CON![NENfAL : $35 NON-PROPTf S30 >100SEAT'S $200 ;,�COMMON VIC. S60 � _�� d� RETAIL SERVICE: LICENSE REQUIRED FEE PERMTT# LICENSE REQiJIRED! FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 ' >25 000sq R s285 VENDIAiG-FOOD S25 =<2S>000 sq.R. 5150 =�RaZEN DESSERT S40 =TOBACCO S110 � NAMECHANGE: a,s AMovN'rD[JE _ $ 185,00 � **'�**PLEASE TUItN OVER AND COMPLETE OT�iER SIDE OF FORM'•••* � � . � ADMIl�TISTRATION Under Chapter 152,Section 25C,Subse�tion 6,the Town pf Yarmouth is now r�uired to hold issuance or renewal of any license or permit to operate a t�usiness if a persqn or company does not have a Certificate of Worker's Compensation Insurance. THE AITACAED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURAN�E ATTACHED OR' WORKER'S COMP.AFFIDAVTT�IGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECI� APPROPRIATELY IF PAID: / YES ✓ NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For pwposes of the limit;ations of Motei or Hotel use,Transient occupancy shall be limited to the temporary and short teim occupancy,ordinarily and customarily associated with matel and hotel use. Transient occupants must have and tie able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than dvrty(30)days,and an aggregate of not more than ninety(9U)days within any'six(6)month periad. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupaucy 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 Transient. POOLS POOL OPENING:Ail swimming,wading and whirlpools wluch have been closed for the sea,son must be inspected by the Health Departmem prior to opening. Contact the�Iealth Department to schedule the inspection three(3) days prior to opewng.PLEASE NOTE:People are NOrT allowed to sit in the pool area until t�e pool has been inspected and opened, : POOL WATF.R TESTING: The water must be tested fior pseudomonas,total colifara►and standard piate count by a State certified lab,and submitted to the He�lth Depart�►ent thre�e(3)days prior to opening,and quarterly thereafter. POOL CLOSYNG:Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENIrTG: A11 food service establishments must be inspe�ted by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three(3)days prior to openu�g. CATERING POLICY: . Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the reqwred Temporary Food Service Application form 72 hours prior to the catered event. These fornas cau be obtained at the Health Department,or from the Town's website at wwwyarmouth.ma.ns under Health Departrnent, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab priQr to opening and monthly thereafter,with sample results submitted to the Healfh Department. Failure to do so vv�ll resutt in the suspension or revocation of your Frozen Dessert Pcrmit until the above teams have been met. OUTSIDE CA�S: Outside cafes(i.e.,outdoor seating with waiter/waitress seivics),mtist have prior approvat from the Board of Health. OUTDOOR COOII�NNG: Outdoor cooking,preparation,or dispiay of any food prodpct by a retai]or food service establishment is prohibited. NOTICE:Fermits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RE'I'URN T'HE COMPLETED RENEWAL APPLICATION(S),AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVAT'IONS TO ANY F�OD ESTABLIS��IENT, MOTEL OR POOL (i.e., PAIN'I'ING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO A.ND APPROVED BY'I�iE BOARD OF HEALTH PR�OR TO COMMENCEMENT. RENOVAT'IONS MAY REQ![JIRE P AN. DATE: /�`�-!� SIGNATURE: e�/"t� � PRIlVT NAME&T'ITLE: o/� �L�/�/1��'6l G�'� x�.iaia✓n � The Commonwealth of Massachusetts �=�� Deparhnent of Industrial Accidents Office of Investigations ' I Congress Street,Suite 100 Boston,MA 02�14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: �K. � 1lV�'�-''" Address: �'/'"� �� a�'' �c�� /� t'J��6'c City/Sta.te/Zip: �� Phone#: .�� 3 Cl�r�� Are y an employer?Check the appropriate boz: Bnsiness Type(required): l.�am a employer with / employees(full and/ 5• ❑ or part-time).* T 6. RestaurantlBar/Eating Establishment 2.❑ I am a sole proprietor or parinership and have no �, �Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. g, �Non-profit [No workers'comp.insurance required] 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing no employees. [No workers'comp.insurance requiredJ* 11.�Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers'comp.insurance req.] 12•0'Othea' 3Any applicant ffiat checks box#1 must also fill out the section 6elow showing their workers'comp�sation policy information. *sIf the corporate officers have exempted themselves,but the corporaLion has other employees,a workers'compensation policy is required and such an organization should check hox#1. I am an employer that is pmviding workers'compexsation insurance for my employees. Below is the policy infornwtion. Insurance Company Name: (J S�L. _�/✓s cr,Cy4/`�� v�S • Insurer's Address: Z/7'� JL 1� (�C�-i � . `'j� �S� City/State/Zip: ""�� i� G �� Policy#or Self-ins.Lic.# 26� ��1 '�1�.rl,��6 Expirarion Date: � "' � �' Attach a copy of the workers'compensallon policy declaration page(showing the policy number and eapiradon date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a I fine up to$1,500.00 and/or one-year imprisonment,as well as civil penaldes in the form of a STOP WORK ORDER and a fine I of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to tiie Office of ; Investigations of the DIA for insurance coverage verification. � I do her¢by� a' and pena ' ofperjury that the infornwtion provided above u true and correc� Sienature: � �� Date• ��`�"C 7 Phone#: ��31�� Ofj`'icial use only. �o not write in this area,to be completed by city or town official City or Town: PermitlLicense# ( Issuing Aathority(circte one): f 1.Board of Heatth 2.Bailding Department 3.City/Ta�vn Clerk 4.Licensing Board 5.Selectmeds Office 6.Other 4 Contact Person- � Phone#• ! I www.mass.gov/dia � � ' q�o' CERTIFICATE OF LIABILITY INSURANCE °��`""�°°"""' 10/18l2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TME CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NE(3ATNELY Ab1END, EXTEND OR ALTER THE COVERA(3E AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTiTUTE A CONTRACT BETYMEEN THE ISSUMICi INSURER(Si, AUTHORI�D REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certi(icabe hoider is an ADDITIONAL INSURED,the p�ifcy�ies�must have ADDITIONAL INSURED provisions or be endorsed. If SUBR06ATION IS WAIVED,subjcct to the terms and conditrons of the pdicy,ceRain policies ms�t require an endorsement A statemeM on this certificate dces nat confer " IKs to the ce�tificate hoWer in lieu of such endorsemeM s. �oouc� Nn� �E • 800 403-2448 e�No:866-82&2424 USI INSURANCE SERVICES LLC A �� . Certiflcate Hanover.com 475 KILVERT ST BLDG B/205 iNsue�s nFr•orcdNo cov�w►ae w►�s WARWICK,RI 02886 i��n: Citizens Ins Co ofAmerica 31534 �� n�n�e: Hanover Insurance Co 22292 TNT FAMILY ENTERPRISES iasu�c: DBA ROUTE 28 DINER INSURER D: 928 ROUTE 28 INSURER E: SOUTH YARMOUTH MA 02664 i��F: COVERAGES CER77FICATE NUMBER: REVISIOPI NUMBER: THIS IS TO CERTIFY THAT THE POLIGES OF INSURANCE LISTED BELOW W1VE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TFE POUCY PERIOD INDICATED. NOTWI7HSTANDING ANY REQUIREMENT.TERM OR OONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NlHICH THIS CERTIFlCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED FIEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS MD CONqTIONS OF SIICH POUqES.UMITS SHOIAM MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF iNSURAI�E ADOL SUBR POLICY NUAiBHi POIICY EFF POUCV E%P L1MtTS X COtiMERC1Al(3EN92Al WBIIRY EACH OCCURRENCE s 1000000 cu�i�noe 0 occuR AM i s 100000 MEo exa�noy one p«aon� s 10000 A N N ZBE 8998515 O6 01/29/2017 01/29/2018 ��r�n��,nov inuuRr s 7 000000 GEN'l AGGREGATE UMIT APPLIES PHt: GENERAL K3GREGATE S ZOOOOOO X Poucr❑r�r ❑�ac �ooucrs-co��oa�cc s 2000000 OTHB2: S AUTOMO&LEWIBILITV � Ne V S ANY AUTO BODILY IN,AJRY(Per person) S OWNW SCtImULED BOqLY IN,�JRY(P.r aocideM) S AUTQS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE a AUTQS ONLY AUTOS ONLV S UM�RBLA LIAB �� EACH OCCURRENCE S EXCF.83 W1B �p�.MqpE AGGREGATE E DED RETENTION$ E VYORKERS COMiPB15RTION - AND 9APLOYHtS'LIABIUTY X STA ---------- ANYPROPRIETOR/PARTNER/EXECUTIVE Y!N E.LEACHACCIDENT S $OO,OOO B OFFICERIMEMBERO(CLUDED'1 � N�A N WHE 7937162 07 04/O6/2017 04/06/2018 (MandaOory in NN) E.L.DISEA^�-EA EMPLOY� S 500,000 �o .�scR�o�ra oF oP�nrioNs e�w. EL.aSEASE-POLICV LIMIT a 500 OQO DESCRIP�ON OF OP9t/�T10N3/LOCATION3/VEMClE3(ACORD 101,/dARional Ranarks ScMCuk,may be altadMd M mon apeca Is requi�d) NAMED INSURED CONT:ROUTE 28 DINER. CERTIFICATE HOLDER CANCELLATION SHWLD ANY OF THE A80VE DESCIaBED POUCIES BE CANCELLED BEPORE THE EXPUtATION DATE TNEREOF, NOTICE WIIL BE DELNERED IN AtxORDANCE WI'TFI THE POLICY PROVISIONS. ; TOWN OF YARMOUTH aur�e¢�R�e�TAmr� 507 BUCK ISLAND ROAD WEST YARMOUTH,MA 02673 �dwL, �� . �198E,201 S ACORD CORPORATION. AN ri9hb reservad. ACORD 25(2016/03) The ACORD name and logo are reglstered marks of ACORD � i �