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Home My WebLink AboutApplication and WC e � , � r _.v_. _ . . .�� d� Towrr oF Ya�ou�BoaRn o . , �..'r� � ��T ,� NOV 0 8 2017 ; � APPLICATION FOR LICENSE/PE - � '' * Please complete form and attach a11 necessazy d^� y ecember �� "'��'� ¢ Failure to do so will result in the return of your application pac et. ESTABLISHMENT NAME: � LOCATION ADDRESS: �3S�`Moid,,� �n_.c � TEL.#:50��-��/� S!S'i/ MAILING ADDRESS: � � E-MAIL ADDRBSS: r ( . OWNER NAME: h�.! CORPORATION NAME APPLIC�IBLE): r� s -' MANAGER'S NAME: �nY►S S = S TEL.#:50��77/-5`l MAILING ADDRESS: S�innP_ � POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operatoz(s)and attach a copy of the certification to this form. l. ' 2• Pool opera.tors must list a minnnum of two employees currently certified in standard First Aid and Cammunity Cardiopuimonary Resuscitation (CPR), having one certified employee on premises at a11 times. Please list the employees below and attach copies of t�eir 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. l. 2. 3. 4• FOOD PROTECTION MANAGERS =CERTIFICATIOIV5: All food service establishments are required to have at l�ast one full-time employee who is certified as a Food Protection Manager,as defined in the �tate Sanitaxy Code for Food Service Establishments, 105 CMR 590.000. Please 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 fite at your establishment. 1. �`f�o�.v�de►n c�r�c,l� �' 2. 1 - � 1�--��r� �, l� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. ��Yl �I(i G �. 2. ALLERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who has Allergen certificarion, as defined in the State Sanitary Code foarar Food Service Esta.blishments, 105 CMR 590.009(G){3}(a). Please attach copies of certification to this applica.tion. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishmen� 1. � 1 Y1S�5 �.0��, ( 2. HEIlVILICH 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 a11 times.� Please list your employees trained in anti-choku►g procedures below and attach copies of employee certifications to this form. The Health Dep�rtment will not use past years'records. You must provide new copies and maintain a file at youar place of business. . � . l. ��S� �-Piul.f'\D�� 2._� L�P�l S 3. 'fi�1��r�e 2.A�.rv►�.1�� 4. RESTAURANT SEATING: TOTAL# ' OFFICE USE ONLY LODGING: LICENSE REQUIItED FEE PERMIT# :LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMiT# B&B $55 CABIN S55 MOTEL $110 —TNN S55 CAMP $55 _SWIMMING POOL�110ea —LODGE $55 TRAILERPARK $105 WHIRI.POOL �110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMTi'# �LICENSE REQUIILED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS 5125 CONTINENTAL S35 NON-PROFIT $30 �>100 SEATS �200 � �COMMON VIC. $60 ��-I —�OLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# ;LICENSE REQUIRED FEE PERMIT#. LICENSE REQUIRED FEE PERMIT# <50sq ft�. $50 >25,Q00 ft. 5285 VENDING-FOOD $25 =Q5,000 sq.ft. $l50 _FROZEN�ESSER�' �40 TOBACCO $110 NAME CHANGE: $is : � AMOITNT DUE _ $ ?bO.O� *****PLEASE TURN OVER AND COM�LETE OTHER SIDE OF FORM***** (��4� -p33��0�4 ADMINISI"RATION Under Chapter 152,Section 25C,Subsection 6,the Town pf 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 WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLET'�D AND SIGNED,OR CERT. OF INSURANCE ATTACHED ✓ OR ' WORKER'S C011vIP.AFFIDAVIT SIGNED AND ATTACHED Tflwn of Yarrnouth taxes and liens must be paid prior to r��ewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LOD�GING ESTABLISHMENTS TRANSIENT OCCUPANCY: For p�irposes of the limitations of Motel or Hotel use,Transient occupancy sha11 be Iimited to the temporary and short term pccupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants must have and b� able to demanstrate that they ma.intain a principal place of residence elsewhere.Txansient occupancy sha11 generally refer to continuous occupancy of not more than thirty(30)da.ys,and an aggregate of not more than ninety(90)days within any siac(6)month period. Use of a guest unit as a residence or . dwelling unit shail not be considered transient. Occuparicy that is subject to the collection of Room Occupancy Excise,as defined in M.G.L.c. 64G ar�830 CMR 64G,as amended,shall generally be considered Transient. PO�LS POOL OPENING:All swimming,wacling and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the I-�ealth Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NO`T allowed to sit in the pool area.until the pool has been inspected and opened. POOL WATER TESTING: The wa�r must be tested for pseudomonas,total coliform and standard plate count by a State certif ed lab, and submitted;to the Health De�artment three (3) days prior to opening, and quazterly thereafter. � POOL CLOSING:Every outdoor in g�ound swimming pool must be drained or covered within seven(7)days of closing. � FOOD SERVICE SEASONAL F40D SERVICE OPENING. All food service establishlnents must bE inspected.by the Health Department prior to openin�. 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 required Temporary Food Service Application form 72 �iours prior to the catered event. These forrns can be obtained at the Health Department,or fnom the Town's we�site at www.Xarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab p�io�to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result uz 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 se�vice),must have prior approval from the Board of Health OUTDOOR CUOKING: Outdoor cooking,preparation,or displa�of any food product by a retail or faod service establishment is prolubited. NUTICE:Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN 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 REPi�RTED TO AND APPRO D BY ARD OF HEALTH PR20R TO COMMENCEMENT. RENOVATI�NS MAY REQ PL • DATE: 1�� (D I�7 SIGNATURE: PRINT NAME&TITLE: Y1 I ACr �� S l�� x�Y.�onvi7 a�.:^ '� UATE(MM/DD/YYYY� • �'��" CERTIFICATE OF LIABILITY INSURANCE ��,: 10/0512017 TFfIS 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 INSURANGE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certiflcate holder is an ADDITIONAL INSURED,the policy(ies)must 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 dces not confer rights to the certificate holder in lieu of such endorsement sy. PRODUCER ONTA �E; Linda Sullivan DOWLING 8�O'NEIL INSURANCE AGENCY P�No ; (SOH�775-1820 aC�: E�� Isullivan oins.com ADDRESS: � 973 IYANNOUGH RD INSURER S AFFORDING COVERAGE NAIC# HYANNIS MA 02601 iwsuReRa: LM INS CORP 33600 INSUREO INSURER B: KOUNADIS ENTERPRISES INC INSURERC: DBA YARMOUTH HOUSE RESTAURANT INSURERD: 335 MAIN STREET IN8URER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 198871 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE IISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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 TypE OF INSURANCE �DL SU R p��Y NUMBER ��EFF �pCY EXP ��M� L7R COMMERCIALGENERALLWBILITY EACHOCCURRENCE $ CLAIMS-MADE �OCCUR PREM SES EaEoxurt'ence $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3 POLICY��E a �LOC PRODUCTS-COMP/OP AGG $ OTHER: a A��B��E�B�V.n, COMBINED SINGLE UMIT S Ea accident ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED N�A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-0WNED PROPERTYDAMAGE $ HIRED AUTOS p�pg Per acddent $ UMBRELLA LIAB pCCUR EACH OCCURRENCE $ �C�VAB CLAIMSMADE WA AGGREGATE $ DED RETENTION � WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N E.L.EACH ACCIDENT $ SOO,OOO /� OFFICER/MEMBEREXCLUDED7 wA wA wA WC531S616095017 05/��/2��7 05/01/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ bOO,OOO If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ rJOO,OOO N/A DE8CRIPTION OF OPERATlON3/LOCA770N3/VEHICLES(ACORD 701,AddYtlonal Remarks Sclredule,may 6e attached if more space is requirad) Woricers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 O6 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certiflcate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-�mpensatioMnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOUID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Town of Yarmouth ACCOItDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE �,,,:F c�., South Yarmouth MA 02664 Daniel M.Cr�ey,CPCU,Vice President—Residual Market—WCRIBMA O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2074/01) The ACORD name and logo are registered marks of ACORD