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Home My WebLink AboutApplication and WC � TOWN OF YARMOUTH BOARD OF HEALTH �� APPLI�ATION FOR LICENSE/PERMiT-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 application packet. ESTABLISHMENT NAME: ., ar � • — LOCATION ADDRESS: r r'" °'" �. TEL.#: �� MAILING ADDRESS: E-MAIL ADDRESS: G✓ �� C �� - Cd O WNER NAME: CORPORATION NA1vIE APPL Ct1BLE): J� MANAGER'S NAME: v t S,�� TEL.#: MAILING ADDRESS: � ;� ca POOL CERTIFICATIONS: c ' 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. :..-7 ' r-.,s 1. 2. � � Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cazdiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of ffieir 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. ,._.,.,,-,._.,.,� I. 2. , _ -:; 3. 4. �,� FOOD PROTECTION MANAGERS=CERTIFICATIOI�IS: �• � 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. 3 Piease attach copies of certification to t.�►►is application. The Health Department will not use past years'records. ,�� You must provide new copies and maintain a file at your establishment. � ," // , �+� ; 1.� ulc� N`r(�(y" a. �l�jl��i '��L�fG,,h ,. C�,�, �' PERSON IN CHARGE: � Each food establishment must have at least one Person In Charge(PIC)o site during hours of operation. 1. � 6� v rn� a. C�� 11 ALLERGEN CER'TIFICATIONS: 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 fo2 Food Service Establishments,105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department wili not use past years'records. You must provide new copies and maintain a file�t your establishment. �.��c� /�i�rs�� 2.�,1�1 c� 1��. C_� HEIMLICH CERTIFICATIONS: All food service establishments with�5 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times.� Piease list your employees trained in anti-chokuig procedures below and attach copies of employee 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. � ItJJ � 2. Il� .�C �l, G 3. G�.,f 4. RESTAURANT SEATING: TOTAL¥k � OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# !LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# , B&B $55 CABIN $55 MOTEL 5110 —INN $55 CAMP $55 _SWIMMING POOL�110ea _LODGE $55 TRAII.ERPARK $105 _WHIRLPOOL $110ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEAT'S 5125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS SZ00�Q �COIYfMON VIC. S6(1 �'�1� _ HOLESALE $80 --RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ;LICENSE REQUIRED FEE PERMIT# LICENSE REQUIItED FEE PERMIT# =<29q >25,000 sq.ft. 5285 VENDING-FOOD S25 ,OOOsq.ft $150 —FROZENDESSER'f S46 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �O.O� *•***PLEASE TURN OVER AND COMPLETE OTFIER SIDE OF FORM*•*•* $��-�— I�f-031�� ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town af Yannouth is now required to hold issuance or renewal of any license or perxnit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. TIiE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLET�D AND SIGNED,OR � CERT.OF INSURANCE A'i'TACHED OR WORKER'S C0142P.AFFIDAVIT�aIGNED AND ATTACHED Town of Yarmouth taa�es artd liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ' APPROPRIATELY IF PAID: YES � NO MOTELS Al'�TD OTHER LOl)GING ESTABLISHMENTS TRANSIEN7'OCCUPANCY: For purposea of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term ioccupancy,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(90)days within any six(6)month period. Use of a guest unit as a residence or . dwelling unit shall not be considered ttansient. Occuparicy 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. POQLS POOL OPENING:All swimming,wafling and whirlpools which have been closed for the season must be inspected by the Health Department prior to operiing. Contact the�3ealth Deparlment 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 coliform and standazd plate count by a State certified lab, and submitted;to the Health Department three(3)days prior to opening,and quarterly thereafter. POOL CLOSTNG:Every outdoor in gKound 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 tbe inspection three(3)days prior to opening. CATERING POLICY• Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Deparhnent by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtatned at the Health Depariment,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: � Frozen desserts must be tested by a Statie certified lab prior to opening and monthly thereafter,with sampie results , submitted to the Hea14h 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 witli waiter/waitress service),must have priar approval from the Board of Health. OUTDOOR COOKiNG: Outdoor cooking,preparation,ar displa�of any food product by a retail or food service establishment is prohibited. NOTICE:Permits run annually from January 1 to December 31. FI'IS YOUR RESPONSIBILITY TO RETiJRN THE COMPLETED RENEWAL APP�,ICATION(S)AND REQUIRBD FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOjOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAIlVT'ING, NEW ' EQUIPMENT,ETC.),MUST BE REPI�RTED TO AND P OVED BY THE BOARD OF HEALTH PRfOR TO COMMENCEMENT. RENOVATIONS MAY A SI'T,E PLAN. DATE: ��I r�� SIGNATURE: PRINT NAME&TITLE: v�l �i'I�,�I li/r� 1'' 4U Rev.10/12/17 CATAHOS-01 APELL '4�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/16/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions 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 endorsement(s). CONTACT PRODUCER NAME: Rogers&Gray Insurance Agency,If1C. PHONE F'0'X $77 $16-2156 434 Rte 134 fac,No,�xc1: (Euc,No�:( ) South Dennis,MA 02660 n"oR�Ess�mail@rogersgray.com INSURER S AFFORDING COVERAGE NAIC# iNsuReR a:Endurance American Specialty insurance Company 41718 INSURED iNsuReR e:Firemen's Insurance Company of Washington,D.C. 21784 Catania Hospitality Group,Inc.,ETAL iNsuReRc:Massachusetts Retail Merchants WCSIG Inc.00000 141 Falmouth Road INSURER D: Hyannis,MA 02601 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. NOTIMTHSTANDING 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS � TYPE OF INSURANCE �ry POLICY NUMBER M/ D A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ��OOO,OOO ci.ninns-iwA�e ❑X occuR PGL10012100100 11/16/2017 11/16/2018 DAMAGE TO RENTED 500,000 . P MISES Ea occurre ce ffi MED EXP An one erson $ 5,�� PERSONAL&ADV INJURY $ �,OOO,OOO GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $ 2,000�000 POLICY�JECT � LOC PRODUCTS-COMP/OP AGG $ 2,000,000 oTHER_ Liquor Liab $ 1,000,000 Al1TOMOBILE LIABILITY COMBINED SINGLE LIMIT a acciden $ ANYAUTO BODILYINJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-p WNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per acc'ident $ $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE SSE00032288045 11/16/2017 11/16/2018 AGGREGATE $ 5,��,�� DED X RETENTION$ � C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y�N 014005032239117 01/01/2017 01/01/2018 500,000 ANY PROPRIETOR/PARTNEWEXECUTIVE � N�A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? SOO,OOO (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) certificate holder as additional insured as respects generai liability when required by written contract or agreement Corporate Offices 141 Falmouth Road Hyannis,MA, Dan'1 Webster Inn 149-151 Main Street Sandwich,MA, John Carver inn 25 Summer Street Plymouth,MA, Hearth 8�Kettle Restaurant 151 Main Street Weymouth,MA, Cape Codder Resort 1225 lyannough Road Hyannis,MA, Hearth&Kettle Restaurant 1196-1198 Main Street South Yarmouth,MA General Liability policy excludes the water parks at the John Carver Inn and the Cape Codder Resort as well as the Beach Plum Spas at the Dan'I Webster Inn,John Carver Inn and the Cape Codder Resort. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Informational Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �� ACORD 25(2016/03) �O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD