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Home My WebLink AboutApplication and WC € � _� _ .. � - � . •a TOWN OF YARMOUTH BO � �� 8 2�17 APPLI�ATION F4R LICENS _ � � E„�,,,_ �_ T � � �" * Please complete form and attach a11 necessa�e ber T �`— Failure to do so will result in the return of your applicahon�cet. ESTABLISHMENT NAME: - � LOCATION ADDRESS: � '� TEL.#: - 7"7 — ' S MAILIN('i ADDRESS: � � E-MAIL ADDRESS: Vd�� ,�� _r,P 1�rn,.K,�u � tY�_I. c�r�n � OWNER NAME: CORPORATION NAME A.PPLICt�1BLE): MANAGER'S NAME: SII��0�. ��,mS TEL.#: MAILING ADDRESS: -�. ' POOL CERTIFICATIONS: The pool supervisor mast 6e 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 Cardiopulmonary Resuscitatian (CPR), having one certified employee on premises at a11 times. Please list the employees below and attach copies of their cerkifications 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. l. 2. 3. 4. FOOD PROTECTION MANAGERS;CERTIFICATIONS: All food service establishments are required to have at l�east 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. Piease attach copies of certification to t�iis application. The Health Department will not use past years'records. You must provide new copies and maintain a�le at your establishment. 1. Y K � ' �, �J��l.t ��5 PERSON IN CHARGE: Each food establishment must have at least one Person Irt Chazge(PIC)on site during hours of operation. � �,YY�G� �¢.��`-�L�: 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the Sta.te Sanitary Code fdr Food Service Es�a.blishments, 105 CMR 590.009(Gx3)(a). Please attach copies of cerkification to this application. The Health Department will not use past years' records. You mast provide new copies and maintain a file at yoar establishmen�. 1. S�a�a. �0�-rn5 2. HEIMLICH CERTIFICATIONS: All food service establishments with �5 seats or more must have at least one employee trained in the Heiml�ch Maneuver on the premises at a11 times.� Please list your employees trained in anti-chokuig procedures belaw and attach copies of employee certifica.tions to this form. The Health Departnneat will not use past years'records. You must provide new copies and maintain a fde at y0uar place of business. i. ��h�i ��LYYI � 2. �Van�2�.�0.. �� 3. o-r 1��2A-�..('nn 4. RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $l10 —INN $55 CAMP $55 _SWIMNIING POOL S114ea. —LODGE S55 TRAILER PARK $105 WHIRLPQOL �I IOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# �LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-lOQ SEATS �125 CONTINENTAL S35 NON-PROFIT' $30 �>I00 SEATS 5200 �ZS �COMMON VIC. �60 �22 �xOLESALE $80 —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMTT# ;LICENSE REQUIRED FEE PERMIT#. LICENSE REQUI$.E?I}��EE pER1VII�'# <50sq ft. $50 >25,000sq ft. �285 VENDING-��+�D $25 =QS,OQO sq.t� $I50 �FROZEN DESSER'� S40 _TOBACCO $110 NAME CHANGE: $IS AMOITNT DUE _ $ ?laO.O� *****PLEASE TURN OVER AND COM�LETE OTHER SIDE C)F FORM***** bo��-1�4-�33! -0� . aDNmvis•rRaTYON Under Cha.pter 152,Section 25C,Subsection 6,the Town af Yarmouth is now required to hold issuance or renewal 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 ATTACHED STATE WC?RKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLE'I`�D AND SIGNED,OR CER'�. OF INSURANGE ATTACHED OR � WORKER'S COlwIP. AFFIDAVIT�IGNED AND ATTACHED Town of Yarmouth t�es and liens must be paid priar to renewal or issuance of yaur permits. PLEASE CHECK APPROPRIATELY IF PAID: ;YES NO MOTELS AND 01'HER LODGING ESTABLISI�VIENTS TRANSIENT OCCUP.ANCY: For piirposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short term occupancy,ordiziarily 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 sha11 generally refer to continuous oc�upancy 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 ar : dwelling unit sha11 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,wading and whirlpools which have been clos�d for the season must be inspected by the Health Department prior to operiing. Contact the I-�ealth Department to schedule the inspection three(3) days prior to opening. PLEASE NO'TE: Peopie are NOT allowed to sit in the pool area until the paol has been inspected and opened. POOL WATER TESTING: The wat�r must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted�to the Health De�artment three {3) days prior to apening, and quarterly thereafter. POOL CLOSING:Every outdoor in gmround swimrning pool must be drained or covered within seven(7)days of closing. ! FOOD SERVICE SEASONAL FOOD SERVICE OPENING: AIl food service establishments 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 POLICY: � Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the requzred Temporary Food Service Application fonm 72 �ours prior to the catered event. These forms ca,n be obtamed at the Health Department,or fnom the Town's we�site at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: � Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Healfh Department. Failure to do so will result ir►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:waiteriwaitress service),must have prior approval from the Boazd of Health. UUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishrnent is prohibited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETLJRN THE COMPLETED RENEWAL APP�.ICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL RENOVATIONS TO ANY FOiDD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPIDRTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUI P DATE: �I I � I '7 SIGNATURE: PRINT NAME&TTTLE: VCl �� Rev.10/12/i� � '`,�!�'�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/05/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSMUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTiFICATE HOLDER. IMPORTANT: If the certiflcate holder Is an ADbiT10NAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to the terms and condltions of the pollcy,certain poticies may require an endorsement. A statement on this cert�cate does not confer righ�to the certlficate holder in Neu of such endorsemerrt s). PRODUCER �E: Linda Sullivan DOWLING 8�O'NEIL INSURANCE AGENCY P�NE . (rJO$�775-'IBZO a ,�,: A��s; Isullivan oins.com 973 IYANNOUGH RD INSURER 8 AFFORDING COVERAGE NAIC A HYANNIS MA 02601 iNsut�Ra: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: RED FACE JACKS INC DBA RED FACE JACKS iNsur�c: � �INSURER D: C 0 THE YARMOUTH HOUSE 335 MAIN STREET INSURERE: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 198866 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POIICY PERIOD - INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L�B pp�Y NUMBER ��Y EFF POLICY EXP VMrt$ LTR TYPE OF INSURANCE COMMERCIAI GENERAL LWBILIIY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR DAMA E T RENTED PREMISES Ee occurrence S MED EXP My orre person $ N/A PERSONAL 8 ApV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑�E a �LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LtABILITY COMBINED SINGLE UMIT a Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDUIED AUTOS AUTOS N/A BODILY INJURY(Per acddent) $ AUTOSWNED PROPERTYDAMAGE $ HIRED AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ S WORKERS COMPENSAIYON X �ATUTE ER� AND EMPLOYERS'LIABILffY Y/N - /� OF CER/MEMB�EXCLU ED ECUTIVE N'A �A �A 6562UB9F70437917 ��J/�s/2��7 05/16/2018 E��"�CH ACCIDENT $ 5�0,00� . (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ SOO,OOO If yes,describa under . DESCRIPTION OF OPERATIONS 6elow E.L.DISEASE-POLICY LIMIT $ SOO,OOO N/A i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 701,Addidonal Remarks 8chadule,may be attachsd if mpe space Is requ�red) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 O6 B,no authorization is given to pay daims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This cert�cate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy prec�des the issue date of this cerGficate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verifiption Search tooi at www.mass.gov/Iwd/workers-compensatioMrnestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTiCE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATVE South Yarmouth MA 02664 Danie M CCro �ey,CPCU,�ce President—Residuai Market—WCRIBMA O 1988-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25(2014/07) The ACORD name and logo are registered marks of ACORD