The URL can be used to link to this page

Home My WebLink AboutApplication and WC � • TOWN OF YARMOUTH BOARD OF HEALTH �� APPLICATION FOR LICENSE/PERMIT-2018 *Please complete form and attach all necessary documents by December I5,20I7. Failure to do so will result in the return of your application packet. ESTABLISHMENTNAME: lrwoo P ace TaxiD: LOCATIONADDRESS: 2.�—��1��0. armout TEL.#: SOH-398-8��6 MATLiNGADDRESS: OY't Main St. South Ya�mouth MA 02664 i-r,.�ILADDRLss: mpurrier thedavenportcompanies ,com OWNER NAME: CORPORATION NAME IF APPLICABLE): M�NAGER°S NAME: �dward Goo win TEL.#: - - 06 - MAILINGADDRESS: or ain . , ou armout , POOL CERTIFICATIONS: ;he p�o�supervisor mvst�e cert:f:ed as a Pool Operator,as regu:rec3 by State laEv. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1 Attached Z � � Pool operators must list a minimum of two employees currently certified in standard First Aid and Communi � � ��11 Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list th -�-1 p �" employees below and attach copies of their certifications to this form.The Health Department will not use pas � � °�� years'records. You must provide new copies and maintain a�le at your place of business. C7 �, �� Attached � � � '' 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 attach copies of certification to this application. The Aealth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. �' - 1 Attached 2. � :� � J PERSON IN CHARGE: �`T� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 'W ��-_ �. Attached z, � � �`""� '� �� -�:r 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 Attached 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich ', Maneuver 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. Attached 2. 3. 4. ' RESTAURANT SEATING: TOTAL# OFFICE USE ONLY (�� p(.{�� {-Q?j�7 LODGING: ��,�, LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $]10 aQl INN $55 CAMP $55 �SWIIvIMINGPOOL$IIOe��p�'�SP�I�{.O�jrtH _LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $IIOea. rb� FOOD SERVICE: �LL� y t4-02q@ LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �.,.�� 0 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 �•O�U'�COMMON VIC. $60 ��lO =��D.KITCHEN $80 —�� RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.fl. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 �Q5,000 sq.fl. $I50 �J� -FROZEN DESSERT $40 _TOBACCO $1]0 NAME CHANGE: $IS AMOUNT DUE _ $ D *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** 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 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 XX NO MOTELS AND OTHER LODGING ESTABLISHMENTS TR4NSIENT OCCIJP�„NCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall 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)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,shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department 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 apened. 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 Deparhnent 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 closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: i All 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 required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Deparnnent,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 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 COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. 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 M EQUIRE A SITE PL DaTE: 11/1/17 SIGNATUR . PRINTNAME&TITLE:Ma��, pi�rri Pr� cci stant �'nntrnl 1 ar Rev.10/12/17 � � Tlze Conzmonwec�lth of Massc�cliusetts Prmt Forrn�� Depccrtment of Industrial Accide�zts � � ��:t� Office of Investigations I ` ' I Con ress Stre t uite 100 _ �� g e� S •�� :n �_, ,,��,��.`/ Boston, MA OZll4-2017 �'��,4�4� u�U�U�.:Mac�s.gov/daa -�- Workers' Compensation Insurance Affidavit: General Businesses Annlicant Information Please Print Legiblv Business/Organization Name: Thirwood Place Address: 237 North Main Street City/State/Zip:_So.Yarmouth, MA 02664 Phone#: 508-398-8006 Are you an employer?Check the appropriate box: Business Type(required): l.� I am a employer with employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �o � Office and/or Sales(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]* �� uP��th Care 4.U We are a non-profit organization,staffed by volunteers, '.� "" with no employees. [No workers' comp. insurance req.] 12�Other Re t iremen t Commun i ty *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **[f the corporate officers have eYempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am c�n emp[oyer that is providing workers'compensation insurance jor my employees. Below is tlze policy information. Insurance Company Name: Zurlch AmeriCan Insurer'sAddress: attaChed City/State/Zip: Policy#or Self-ins. Lic. # WC 819 6 0 3 5 Expiration Date: 3�1/18 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 Ixereby c rtify,under tlie pair�nd penalties of perjury t/zat tlae information provided above is true and correct. Si natur �� ^ Date: 11/1/17 Phone#: 508-398-229.3 Official use only. Do not write in t/iis area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circte 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.gov/dia � ACO� DATE(MMIDDlYYYY) � `� CERTIFICATE OF LIABILITY INSURANCE 2,8,20�� 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. iMPORiANT: If tne certificate fioider is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS ViIF►IVED,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 NAME:CT Kristina Converse E. K. McConkey&Co. (Valley Forge) PHONE ,484-965-9623 F"c o•484-965-9627 2555 Kingston Road, Suite 100 E-MA�� ,kconverse vfcadvisors.com Ydrk PA 17402 @ � INSURER S AFFORDING COVERAGE NAIC# � �n,suaeRn:Zurich American 16535 INSURED DAVEN-1 INSURER B: Thirwood Place L.P INSURERG: c/o Davenport Realty Trust 20 North Main Street INSURER D: South Yarmouth MA 02664 INSURER E: � INSURER F: � COVERAGES CERTIFICATE NUMBER: 1336555519 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 POLICY EFF POLICY EXP � LTR TYFE OF INSURANCE INSD VWD POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A y COMMERCIAL GENERAL LIABILI7Y GLO8196255 3l1/2017 3!1/2018 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X❑OCCUR pREM SES Ea ccurtence $500,000 MED EXP(Any one person) S 1,000 ?ERSONP.L€AD\�INJURY 51,OQQ,OQO GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $2,000,000 X POUCY❑PR� �LOC PRODUCTS-COMP/0P AGG 52,000,000 JECT " OTHER: $ A AUTOMOBILE uAeILITY BAP8196256 3l1/2017 3/1/2018 Ea accident � $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ AUTOS�E� AUTOSULED � � BODI�YINJURY(Peraceident) $ NON-OWNED AMAG $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ . EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ q WORKERS COMPENSATION WC8196035 3/1/2017 3/1/2018 X STATUTE ERH � AND EMPLOYERS'LIABILITY �' ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N�A E.L.EACH ACCIDENT $1,000,000 � OFFICER/MEMBER EXCLUDED? � . (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 � � DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 701,Additional Remarks Schedule,may be attached if morc space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Route 28 ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth MA 02664 USA AUTHORIZED REPRES� '��,f� O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD