The URL can be used to link to this page

Home My WebLink AboutApplication and WC1 I J S��I I� � �u�� ' TOWN OF YARMOUTH BOARD OF H�t� ,�'�� NOV � ; ZQ�� APPLICATION FOR LICEN�, ,� : `� �� * Please complete form and attach a11 necess : o u��ht y Dece E�'T Failure to do so will result in the return of your application packe�. ESTABLISHMENT NAME: T ID• ?- LOCATION ADDRESS: 0�.3 lJ, TEL.#: �— 'e�� MAILING ADDRESS: 3 E-MAIL ADDRESS: �c-`�6C� C.f�l�C� 4 �P i�.�csM OWNER NAME: ��!- �!' i ��b` CORPORATION NAME(IF APPLICABLE�: MANAGER'S.NAME: ��' (�'�,�� TEL.#: SZ� - -<<'j,�Q MAILING ADDRESS:_ S�-t G�Je�S�' �JcCn��7�'"�1 � ��c�rnvT-�I 6� i'y+� OZ�7 POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operat.or,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 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 maintain a file at your place of business. 1. 2, 3. 4, � FOOD PROTECTION MANAGERS -CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection M anager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach co ies of certifi � cation to this li p app cation. The Health Department will not use past years records. You must provide new copies and maintain a file at your establishment. 1. � 1! C-�� „�j �� 2; PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. : 1. _ \ iar �.�_��J�1�� 2. ��^iC � l-�(.�/` � ALLERGEN CERTIFICATIONS: 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 provi new copies and maintain a file at your estabGshment. �. 5e� ,c� 2. V i <', �I ,� � �� HEIMLICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 1Vlaneuver on the premises at all times. Please list your employees trained in anti-chaking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. ' You ust provide new copies and maintain a file at your place of business. 1. I.F�C'.{ 2. ' 3. 4. ' RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LQDGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 �OTEL $110 INN $55 CAMP $55 �SWIMMINGPOOL$110ea. _LODGE $55 _TRAILER PARK $105 -``'� .,�WHIItLpOOL $110ea. FOOD SERVICE: c�.��(,� , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE „�jvfi�'� LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 - NON-PROFIT $30 �>100 SEATS $200 � _COMMON VIC. $60 t`� WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 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 DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ o2,�p O . Q� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** �o�t F�<<O -612�Q—�� _ �E I 4`• . � ADMI1vISTRATION � � Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal ' af any license or permit to operate a business if a person or company does not have a Certificate of Worker's � Compensation Insurance. THE ATTACH�D STATE WORKER'S COMPENSATION INSURANCE '; 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 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 sha11 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 thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)montl;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 Roorn Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. ; POOLS � ; POOL OPEl�iING:�11 swimming,wading and whirlpools which have been closed for the season must be inspected j by the Health Department prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People aze 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 coliform 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 elosing. FOOD SERVICE SEASONAL FOOD SERVICE OPEl�TING: 4 All food service establislunents 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 POLIC�Y: ( 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.yarmouth.ma.us under Health Departrnent, � Downloadable Forms. i � 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 Boazd of Health. � OUTDOOR COOKING: ' Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NO�'ICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. 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 i TO COMM NCEMENT. RENOVATIONS MAY R PLAN. � � DATE: t� � SIGNATURE: ; PRINT NAME&TITLE: -��-�� /',b OcrY�-� I � Rev.10/12/17 . � � ! 62 (Policy Provisions: WC 00 00 00 C) /z 61 ZQ L�VFQRMATION PAGE �G WOR�ERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: HARTFORD ACCIDENT AND INDEMNITY COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 NCCI Company Number: 10448 THE Company Code: 5 HARTFORD �n � rn N O Suffix � LARS RENEWAL � POLICY NUMBER: 76 WEG ZQ6162 01 N Previous Policy Number: 76 WEG ZQ6162 � HOUSING CODE: 76 o, 1. Named Insured and Mailing Address: SEA DOG CAPE COD LLC N (No., Street,Town, State, Zip Code) DBA SEA DOG BREW PUB � � N 0 23 WHITES PATH � FEIN Number: SOUTH YARrZOUTH, N!A 02664 � State Identification Number(s): � UIN: = The Named Insured is: LIMITED LIABILITY COMPANY — Business of Named Insured: �STAURANT - FULL SERVICE (WAI — Other workplaces not shown above: 23 WHITES PATH � SOUTH YARMOUTH MA 02664 — 2. Policy Period: From 07/07/17 To 07/07/18 � 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: PAYCHEX INSURANCE AGENCY INC/PAC � PO BOX 33015 = SAN ANTONIO, TX 78265 — Producer's Code: 250881 = Issuing Office: THE HARTFORD 3600 WISEMAN BLVD. � SAN ANTONIO TX 78251 — (877) 287-1312 - Total Estimated Annual Premium: $2,351 - Deposit Premium: = Policy Minimum Premium: $21� MA — Audit Period: �AL Installment Term: = The policy is not binding unless countersigned by our authorized representative. — Countersignedby �`�'`�"� C`��z'�-�' 05/21/17 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 05/21/17 Policy Expiration Date: 07/0 7/18 ORIGINAL ` INFORMATION PAGE (Continued) Policy Number: 75 wEG ZQ6162 � „ , , Y 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: 1KA i 3 I B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. ' The limits of our liability under Part Two are: ' Bodily injury by Accident $100,000 each accident Bodily injury by Disease $500,000 policy limit Bodily injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 00 04 22B WC 20 03 03D WC 99 03 OOD WC 00 04 14 WC 20 03 01 WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Classifications Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 9079 209, 000 1.09 2,278 RESTAURANI' NOC MA RATE DEVIATION PREMIUM CREDIT ( .20) (9037) -456 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1, 822 EXPEI�TTSE CONSTANT (0 9 0 0) 3 3 8 t MASSACHUSETTS DIA ASSESSMEN'I' 5.600 PERCENT 128 i TERRORISM (9740) 209, 000 .030 63 TOTAL ESTIMATED ANNUAL PREMIUM 2,351 i Total Estimated Annual Premium: $2,351 Deposit Premium: Policy Minimum Premium: $217 MA � Interstate/Intrastate Identification Number: NAICS: Labor Contractors Policy Number: SIC: 5812 UIN: ' NO. OF EMP: 000010 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 05/21/17 Policy Expiration Date: 07/07/18 , INFORMATION PAGE (Continued) Poiicy Number: 76 WEG ZQ6162 � . � .. 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: ' Bodily injury by Accident $100,000 each accident Bodily in jury by Disease $5 0 0,0 0 0 policy limit Bodily injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: � ALL STATES EXCEPT ND, OH, WA, WY, US TERRITORIES, AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: WC 00 04 22B WC 20 03 03D WC 99 03 OOD WC 00 04 14 WC 20 03 01 WC 20 03 02A WC 20 04 01 WC 20 04 05 WC 20 06 01A 4. The premium for this policy will be determined by our Manuals of Rules,Classfications, Rates and Rating Plans. All information required below is subject to ver�cation and change by audit Premium Basis Classi�cations Total Estimated Rates Per Estimated Code Number and Annual $100 of Annual Description Remuneration Remuneration Premium 9079 209,000 1.09 2,278 RESTAURANT NOC MA RATE DEVIATION PREMILJM CREDIT ( .20) (9037) -456 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM 1,822 EXPENSE CONSTANT (0900) 338 MASSACHUSETTS DIA ASSESSMEIVT 5.600 PERCENT 128 TERRORISM (9740) 209,000 .030 63 TOTAL ESTIMATED ANNUAL pREMIUM 2,351 Total Estimated Annual Premium: $2,351 Deposit Premium: Policy Minimum Premium: $217 MA Interstate/lntrastate Identification Number: Labor Contractors Policy Number: NAICS: SIC: 5812 UIN: NO. OF EMP; 000010 Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 05/21/17 Policy Expiration Date: 0 7/0 7/18 , SEADO-1 OP ID:KS A`,oRo� CERTIFICATE OF LIAB DA7E(MM/DDIYYYY) ILITY INSURANCE 06/30/2017 , THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ; CERTIFICATE DOE3 NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: ff the certificate holder is an ADDRIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, subject to the terms and condittons of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemen s. PRODUCER ,CON„�,,,E"� Dennis Office Bryden 8 3ullivan Ins Agency of Dennis Inc. PNONE .508-398-6060 F'� 485 Route 194,PO Box 1497 e-Ma� � •508-384-2267 30.Dennis,MA 02660 " Dennis Office INSURE 8 AFFORpING lb{/ERAGE NAIC# IN8URERA:Af17 uard Insurance Co �Nsu� Sea Dog Brew Pub Cape Cod LLC 23 Whtte's Path Unit INSURERB: South Yarm outh,MA 02664 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOIWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LT�R 7YPE OF INSURANCE B POLICY NUMBER POLICY EFF POUCY EXP �,� A X COAAMERCIAL GENERAL LWBILI'ry EACH OCCURRENCE $ 'I,OOO,OO CLAUNS-NIADE �OCCUR SEBP844134 06/01/2017 06/01/Z018 pREMISES Eaoccurrence $ �0��0 /� X I�quor liability SEBP844134 MED EXP(Anyone person) $ 5,�� /01/2077 06/01/2018 pERSONAL&ADVINJURY $ �,�0,�� GEN'L AGGREGATE L�YIITAPpLIES PER: GENERAL AGGREGp7E $ Z��IO� POUCY❑jE�T ��OC PRODUCTS-COMP/OP AGG $ 2,000, oT"ER' Liquor Li s 1,000,00 AUTOMOBILE LIABIUiY EaM�dent IN E LWIR $ �A� BODILY INJURY(Per person) $ AALUT�NED �SC�H,E�DULED BODILY MJURY(Per accidenq $ HIREDAUTOS NON-0WNED AUTOS Per acc�deM�GE $ S UMBRELLA Llpg OCCUR EACH OCCURRENCE $ EXCE83 W46 CLAidS�AADE AGGREGATE $ DED RETENTIpN$ VYORKERS COMPENSAiION 3 AND EYPLOYERB'LIqg�UTy Y/N STA7UIE ER ANY PROPRIETOR/PAR7'NER/EXECUTIVE OPFICER/MEMBER EXCLI�Ep? ❑ N�p E.L.EACH ACCIDENT (Manda6ory In NH� $ Ifyea describe under E.L.DISEASE-EA EMPLOYE $ DESCRIP710N OF OPERATION3 below E.L.D13EASE-POLICY LBu1R $ DESCRIPTION pF ppERp71pN3/LOCATIpNB/VENICLE3(ACORD 101,Additla�al Rerrarks gchedule,may be atmched if more s pace is roquired) CERTIFICATE HOLDER CANCELLATION TOWNOFY SHOULD ANY OF THE ABOVE DESCRIBED POLiC1ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Town of Ysrmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 �TM�o�P�sewTarnE '�� l.J� iiC"""`�'`�'� �1988.2014 AGORD CORPORATION. All rights reserved, ACORD 25(2074/01) The ACORD name and logo are registered marks of ACORD