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Home My WebLink AboutApplication and WC{ , ' `� ` ` ,, �` RECENED � TOWN OF YARMOUTH BOARD OF�EAi�T� ,; � APPLICATION FOR LICEN��I-, 2�1 '�y Q�C 1 1 z'�117 � '` * Please complete form and attach all necessa�y d��'��i�i��ec mb Failure to do so will result in the retu�of your application . T ; ESTABLISHMENT NAME: . C - TAX ID• �.� ( LOCATION ADDRESS: `�'O • CZ.oc9``rE 2-�',iu�fi �(�f� y1.,�r1-i+ TEL.#: �-`�-f��``1�p_�5�� MAILING ADDRESS: ��(L�u`��, 2SC � W eS'� �(J'0-Yv�°u�t� --�{�. ��5 '�'`� E-MAIL ADDRESS: ,(_,,, OWNER NAME: a. � � CORPORATION NAME (IF APPLIC LE): `�7 a MANAGER'S NAME: (��s aa TEL.#: -b S MAILING ADDRESS: e,:�+C,u• tl . �-� � � 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. �E�-� � �-��,�'g` _ - _ Pool operators must list a nimum 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 Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please atta.ch copies of certification to this application. The Health Department will not use past years'reeords. You must provide new copies and maintain a file at your establishment. 1. ��'�A�� - �/,'�- L C� �. � 2: PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. i. �_�_ -��-- -�';��- -- _�� _�____--------______-__ _ _ - -- __ _ _ � . 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 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 provide new copies and maintain a file at your establishment. 1. �/� �/�L l.� , �„�/��..�--rc r 2. 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-choking 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.�.-v�i J ��o�,y 2.�� C-1�� 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 MOTEL $110 ' INN $55 CAMP $55 SWIMMING POOL$110ea _LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMI LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' �0-100 SEATS $125 �F --� CONTINENTAL $35 NON-PROFIT $30 I _>100 SEATS $200 �COMMON VIC. $60 �7 WHOLESALE $80 ' —RESID.KITCHEN $8U RETAIL SERVICE: 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: $i s AMOUNT DUE _ $ /85-Od *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** , �SOt��-�-17--�31�--0� , i + ` ,a 1 � ADMINISTRATION ; Under Chapter 152,Section 25C,Subsection 6,the Town of 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 COMPLETED AND SIGNED,OR � � CERT. OF 1NSURANCE 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 i APPROPRIATELY IF PAID: , ` YES�_ NO � i MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha1T 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 mainta.in a principal place of residence elsewhere.Transient occupancy shall 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 six(6)month 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 Room Occupancy ; Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, sha11 generally be considered Transient. i POOLS i ; POOL OPEI�TING:�11 swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health D�partment prior to opening. Contact the Health Deparhnent 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 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)da.ys of ' elosing. � � � _ � FOOD SERVICE _ _ _ _ ,_ SEASONAL FOOD SERVICE OPENING: I All food service esta.blishments must be inspected by the Health Deparlment prior to opening. Please conta.ct the ; Health Department to schedule the inspection three (3) days prior to opening. � I CATERING POLICY: j Anyone who eaters within the Town of Yarmouth mus� notify the Yarmouth Health Department by filing the E 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.varmouth.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 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 Board of Health. OUTDOOR COOKING: � Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. � i _ , _ ___ _ ; NOTICE: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 TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: I�—I�2. - I�-' SIGNATURE:� . _ � PRINT NAME& TITLE: � ; Rev. 10/12/17 1 �-. , r� The Commonwealth ofMassachusetts Department of Industrial Accidents � Office of Investigations ` 1 Congress Street, Suite I00 Boston, MA 02114-2017 www.mass,gov/dia Workers' Compensation Insurance Affidavit: General Businesses ' Applicant Information Please Print Legibly Business/Organization Name: C��Ct 1� � (�r� � _ Address: ��,�U�L 2.� . City/State/Zip: �J��'�(�.t1v1��.t`�-,�� 26`� Phone #: ��- ��L.� .—�-(;�-� -�5`�,,� Are you an employer? Check the appropriate box: Business Type(required): ; 1.�I am a employer with � employees(full and/ 5. ❑ Retail or part-time).* 6. �'RestaurantlBar/Eating Establishment ' -- -- - -- - — _ — --_ - . - -- —— _— _ 2. I am a sole proprietor or partnership and have no � 7. ❑ Office and/or Sa1es(incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp.insurance required] g• ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing : no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees: [No workers' comp. insurance req.] 12.❑ Other ' *Any applicant that checks box#1 must aiso fill out the section below showing their workers'compensation policy information. . **If the corporate o�cers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an , organization should check box#1. I am an emp[oyer that is providing workers'c mpensation insurance for my employees. Below is the policy information. ' Insurance Company Name: ��y�� _ �C�C�i��N S �v�G C N �� Insurer's Address: �� r�.� ��-�� O (,'�L, City/State/Zip: ��(A.V��n� S — �� - b�� ` Policy#or Self-ins.Lic. # C � l �,^�L,� Z � Expiration Date: �u /2S�20 t p Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). '. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to�1,�(7.�and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ' of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. __ _ I Si ature:r.� Date: 2-- � - 2� l� Phone#: t�-�� > Officia[use only. Do not write in this area,to be comaleted by city or town officiaL City or Town: PermitlLicense# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City!Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone#: ; ' www.mass.govldia I i r�� PAGUA-1 OP ID: DS ACOR�� DATE(MM/DD/YYYY) `,� CERTIFICATE OF LIABILITY INSURANCE 12/12/2017 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 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). PRODUCER CONTACT . Bryden&Sullivan Ins Agency PHONE H annis Office . F� 88 Falmouth Road ac No �e:508-775-6060 ,o,ic No: 508-790-1414 Hyannis, MA OZF1O'I ADDRESS: Hyannis Office INSURER S AFFORDING COVERAGE NAIC# �NsuReRa:The Hartford 22357 INSURED Luis Paguay iNsuReRe:SCOTTSDALE INSURANCE COMPANY 41297J dba Grand Cafe 34 Circuit Rd North wsuReR c: West Yarmouth, MA 02673 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. 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 ADDL U POLICY EFF POLICY EXP . � � LIMITS - � LTR � D WVD POLICY NUMBER MM/DD/YYYY �MM/DD/YYW B X COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ �,OOO,OO CLAIMS-MADE �OCCUR CPS2615425 04/25/2017 04/25/2018 pREMISES Ea occur ence $ 50,00 MED EXP(Any one person) $ 5,0� PERSONAL&ADV INJURY $ 'I,OOO,OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z,OOO,OO X POLICY�jE� � LOC PRODUCTS-COMP/OP AGG $ Z,OOO,OO OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION . X PER OTH- : AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N OHWECAAZSYO 05/04l2017 05/04/2018 E.L.EACH ACCIDENT $ SOO,OO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOO,OO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate issued for insurance verification Liquor Liability$1,000,000 Per Occurrence $2,000,000 Aggregate CERTIFICATE HOLDER CANCELLATION YARM003 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 MAIN ST S.YARMOUTH, MA 02664 AUTHORIZED REPRESENTATIVE �� Hyannis Office a - � �,, � �q�\ . �. t�; I P.1.; ...-. " � i.�'��G��\J ��. .,.+:... f, . ]'; i~ O 7988-�4��C�,(dRf��, � � ;�T�3t�,,��,r�g�s reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks o A�[��4G� �;;�;��;��tly