HomeMy WebLinkAboutApplication and WC� TOWN OF YARMOUTH BOARD OF HEALTH
j APPLICATION FOR LICENSElPERMIT-� �18 �S� 2p�7
�' •Please complete form and attach all n�essary documents by , e r�6
Fai(ure to do so will result in the retnrn of your applicahon pac e�t.
ESTABLISHMENT NAME: � • -
LOCATION ADDRESS: TEL.#: O�' � -
MAILING ADDRESS:
E-MAIL ADDRESS ' C.� t'_ ,c_cf1� !^ .S,$�'OS��'a�P C'6�
OWNER NAME: �
CORPORATION NAME(IF APPLICABL$):
MANAGER'S NAME: TEL.#: - - y S�
MAILING ADDRESS: _'��r,n�,�n n1h��1P_
POOL CERT�ICATIONS:
The pool supervisor mest be certifiod as a Pooi Operator,ns required by Stxte law. Please list the designated
Pooi Operator(s)and attach a copy of the certificatian to this form.
i. �� 2.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community 2 � �
Cardiopulmonazy Resuscitation(CPR),having one certified employee on premises at all rimes. Please list the � � �
employ�s belaw and attach copies of their certifications to this form.The Health Department wW not use past r- ("�
years'records. You mnst provide new eopies and�aintain a file at yoar ptace of bvsineas. z � m
t N�`R 2. m -,o m
3. 4. � �
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FOOD PROTECTION MANAGERS-CERTIFICATIONS:
All food seivice estabtishments are required to have at teast one futl-rime employee who is certified as a Food
Protection Manager,as defu�ed in the State Sanitary Code for Faod Service Establishments, 105 CMR 590.400.
Please attach copies of certification to this apglication. T6e Health Depsrhme�t will Aot ese past yws'ru�rds.
You must provide new rnpies and maintain s file at yoar estAblishment. T. �
1. N` �r 2.
�.:�..
PERSON IN CHARGE:
E�ch food establishment must have at least one Person In Charge(PIC)on site during hours af opet�ion.
1. (�� �� �i-L�M i��.IJ 2.
ALLERGEN CERTIFICATIONS:
All faod service establishments are required to have at least one fWl-time empioyee who has Allergen certification,
as defined in the State Sanitary Code foa�Food Service Establishments,105 CMR 590.0(�{Gx3xa). Please attach
capies of cettification to this application. T6e Hcs�lt�Departme�t wilt aot nse past years'records. Yoa mast �
provide new copies and maintain a Sk�t your estxblishmen�
t. N 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or ma�+e must have at least one employee trained in the Heitnlich
Maneuver on the premises at all times. Please list your employ�s trained in anri-choking procadures below and
attach copies of empioyee certifications to this form. T'he Health Department will not use past y�rs'recorda
You mast provide aew copies aad msintain a file st yoar place of bnsiness.
i. �'� 2.
3. 4.
RESTAURANT SEAT[NG: TOTAL#
OFFICE USE OATLY
LODGING:
LICENSEREQUIRED FEE P IT# LICENSEREQUtRED FEE PERMITi1 UCENSEREQUIRED FEE PERMIT#
=INN SSS CABIN $55 M07'EL 5110
_IADGE S55 ' lTRAtLER PARK S OS WHIMRLPOOL�4S11�
— 6a��.-h-�76-7
FOOD SERVICE: �,,, � '
L[CENSE REQUIRED FEE PERMiT� LICENSE REQUIRED FEE P IT UCENSE REQUIRED FEE PERMIT#
0-IIKI SEATS Sl25 LCONTINENTAL S35 ���IZ– NON-PROFIT S30 '
>IOOSEATS 5200 COMMONVIC. S60 WHOLESALE SSO �j �(
—RESID.KITCHEN S80 17O{�F���""G�Sb
RETA[L SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT#
<50sq R SSb >25,000sq ft 5285 VENDING-FOOD S25 ""� `
_�Z.i,000 sq.R SI50 =FROZEN DESSERT 540 TOBACCO SI 10
1�AME CHAIVGE: SIS AMOUNT DUE _ $ jQ,�
**•**PLEASE TURN OVER AND COMPLETE OTNER S1DE OF FORhI"**•
ADMI1vISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Tawn of Yarmouth is now required to hold issuance or renewal
of any ticense or pe�mit to operate a basiness if a person ar compaay does not have a Certificate of Work$r's
Gompensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION 1NSURANCE
AFFIDAV[T MUST BE CQMPLETED AND S[GNED,OR
GERT.OF INSURANCE ATTACHED ✓
OR
WORKER'S COMP.AFFIDAViT SIGNED AND ATTACHED "
Town of Yamtouth taxes and lieos must be paid priar to reuewai or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
yE� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRAN$iENT OCCUPANCY: For purposes of she limit�ions of Motel or Hotel�,Transiern oc�upancy shall be
limited to the temporary and short term occupancy,ordinarity and customarily associated with motel and hotel use.
Transient occupants must have and t�e able to demonsttate that they maintain a princi�l place of residence
elsewhere.Transient occupancy shall generaily refer to continuaus occupancy of not more than thirty(30)days,and
an ag�regate ofnot more thar►ninety(90)daYs within an3'six(6)month period. Use of a guest unit as a residence or
dwelling unit shalt not be cronsidered transient. Occupancy tbat is subject to the cotl�tion of Room Occupancy
Excise,as defined in M.G.L.c.64G ar 83Q CMR 64G,as ame�ed,shatl gen�'a11y be consideret3 Tr�nsiem.
POOLS
POOL OPEMNG:All swimming,wading anci whirlpools wtrich have been closed for the season�be inspected
by the Heaith I�eirt�xiar to opening. Contact the Heaith�I��pa�?ent to scheduk tbe iaspeetion th�(3)
days prior to speata�PLEA5E NOTE:People ace NOT alio �d to srt in the pool area until the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,totat coliform and standard plate rnunt
by a State certified lab,and submitted to the Health Depertment three(3)days prior to opening,and quarterly
thereafter.
POQL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(�days of
closing.
FOOD SERVICE
SEASUNAL�OOD SERVICE OPENING:
Ali food service estabiisl�ments must be iaspected by the Health Department prior to opening. Please contact the
Health Departmern to schedule the inspachon three(3)days prior to opening.
CATERING POLICY:
Anyo�who caters within the rowa of Yaaimouth must notify the Yarmouth Health Deparm�ent by filing the
required Temporary Food Service Application form 72 ho�us prior to the catered event. These forms can be
obtained at the Heaith Department,or fcom the Town's wei�site at www.yarmouth.maus under FIealth Department,
Drownlosdable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab grior to openin�and monthly theneaiier,with sample results
submitted to the Health Department. F�Iwe to do'so will result in the snspension or revo�tion of your Froze»
Dessett Permit untii the above terms have beEa met.
OUTSIDE CAF�S:
� Outside cafes{i.e.,outdoor seating with waiterlwaitress sexvice),must have prior appravat firom the Board of Health.
OUTDOOR COdKING:
Outdoor cooking,preparation,or display ofany food product by a retail orfood service estahli�t is pro�ibited.
i
NOTICE:Permits nm annually from Jan�ary i to December 3 t.IT IS YOUR RESPONSIBILITY TO RET'tJRN
THE COMPLETED RENEWAL APPLICATtON(S}AND REQUIRED FEE(S)BY DECEMBER 15,2017.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENF,ETC.),MUST BE REPORTED TO'AA1D APPRO BY THE BOARD OF HEALTH PRIfJR
' TO COMMENC MENT. RENOVA'�70NS MAY REQUIRE S P _
DATE: � I / SIGNATURE:
PRINT NAME&TITLE: i? d i'� /7�/ �'I OG�/?P/�
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_ ,4co e CERTIFiCATE OF PROPERTY lNSURANCE 6 27�;
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THIS CERTiFlCATE t3 lSSUED AS A Mf1TTER OF INFQRNATION ONLY AND CONFERS NO RWHTS UPOt�t THE CERTlFlCATE HOLDER THIS
CERTIF�ATE DOES NOT AFFIRMATNELY OR NEGATNELY AIIEND, EXTEND OR ALTER THE C01iERAGE AFFORDED BY THE POIJqES
BEI.OW. THIS CER7IFlCATE OF IN.SilRANCE DOES NOT CONSTiTUTE A CONTRACT BETNfEEN THE ISSUING INSURER(S� AUTHORIZED
REPRESENTA7IVE OR PRODUCER,AND THE CER77FICATE MOLDER.
If this catlfica6e is being prepared for a party who I�s an insuraWe i�st�est�the ProPeRY.do not use�is fo�m. t�e ACORD 27 or ACORD 2$.
� N� Michael Cali
� NFP Property � Casualty Services, Inc_ � (617)405-1526 F��,�, tst��s+�-iaz2
141 Longaater Dr #101
A�OORESS•
Norwell MA 02061 � 00118843
� nr�ame�� wuc s
� NSIA�tA:PHILADSLPHIA INSDRANCBS CO'S
Co�pass Rose Hospitality, Inc.
NSUR�e:
a�� rfain street. Rt. 6A
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w�o:
Yarmouth Port MA 02675
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COVERAGES CERTIFICATE NUMBER.'C�'1762704739 REVISION NUMBER:
LACA710N OF PRB�B/OF.St:RPTIOX OF PROPBtTY(ACach ACORD 101.HddllorW Remxl�s Sd�edWe,N m0ie spaa is�)
Loc# 00001: 277 Mai.n Street. Rt. 6A (Ina) Yazmoutla Port 1� 02675
� 8�e Attached Overflow Paqes „
THIS IS TO CERTIFY TFIAT THE POIJCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
', INDICATED. NOTWITHSTAMDING ANY REQUIft81AENT,TERAII OR C�I�TION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS
! CERTIFlCATE MAY BE ISSUED OR INAY PERTAIN,THE INSURANCE AFFORDED BY THE POLlCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
IXCWSIONS AND CONDITIONS OF SUCH POLICIES.UMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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sr�aa�oo�na+s�on�e c�ne�s t�acor��m,��sd.ar.,r���s�.�r.a�
The Cooperative Bank of Cape Cod is firat postioa.
� IIS Small Busiaess Ac�inistration]
C/O Cape � Islaad Community Develop�eat has been listed as 2nd Mortgagee snd Lenders Loss
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I C6RTIFICATE HOLDER CANCELLATION
sHouw nrnr oF Tt+�neove�scweEn�Es�cnnceu.�c�seFo�
n+e �feanoa nx� TM�, Nor+ce wn.� ee oeuve�ro �N
The Cooperatine Bank of Cape Cod �►CCORDANCE wRH 711E POUCY PRO�ONS.
695 Attucks Lane
Hyaanis, MA 02601 A°����
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Daniel Whyte/DANW �
ACORD 24(Z009r09) �199''.�-2009 ACORD CORPORATION. Ail rights reserved.
INS024�o�os> The ACORD name and logo are registered rr�rlcs of ACORD
A Worker's Comoensation and �mqioyer's Liabilitv Policv
v�Berkshire Hathawa NorGUARD Insurance Company- A Stock Co.
♦ � y Policy Number COWC833337
�..,,���� Insurance Renewal of NEW
�A fiG UARD Companies NCCI No. [25844]
Poficy Infocmation Page
[1]Named Insured and Mailing Address Agency
;Compass Rose Hospitaliry Inc NFP PROPERTY&CASUALTY SERVICES INC.
277 Main St Rt 6a 141 Longwater Drive
�Yarmouth Port, MA 02675 #101
Norwell, MA 02061
Agency Code: VTPOUL36
? Federal Employer's ID Insur�ed is Corporation
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[�] Policy Period
From luly 1, 2017 to]uly 1, 2018, 12:01 AM, standard time at the insured's mailin9 address.
[�] Coverage
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! 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 �re:
3 Bodily Injury by Accident - each accident $500,000
� Bodily Injury by Disease - each employee $500,000 _ _
; Bodily Injury by Disease - policy limit $500,000
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! C. Other States Insurance - Part Three of this policy applies to ali states, except any state listed in
� item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
i
� D. This palicy includes these endorsements and schedules:
(
� See Extension of Information Page - Schedule of Forms
[ ] Premium
; The Premium Basis and, therefore, the premium will be determined by our Manuai of Rufes,
i Classifications, Rates, and Rating Plans. Ali required information is subject to verifiwtion and cMange by
� audit. (Continued on another page)
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T�►tal Estimated Policy Premium � 959
Tptal Surcharges/Assessments $ 30.00
T tai Estimated Cost 989.00
Page- 1 - InformaUon Page
MG � : COWC833337 WC OQOOOlA
Dat� : 07/28/2017
MANbTE
�
Issuing Office: P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 •wwyv.guard.com