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Home My WebLink AboutApplication and WC� . .� RECE D �� I I � ► TOWN OF YARMOUTH BOARD OF HEALTH , � . �� r �� . �� APPLICATION FOR LICENS�� `' Q � �� 7 ` �' ``°� * Please complete form and attach all necess�do�c�rnerrt�b�Dec mb - pT Failure to do so will result in the rettaFn of�our��p��ic�o pac ce . ESTABLISHMENT NAME: 1 1,1� (C iL T�- �(�i T X ID: � � LOCATION ADDRESS: 1l� t.l; E 2'�' �LC�N ►� �MC t,lT�-1 TEL.#: MAILING ADDRESS: ��"ir�/lt� E-MAIL ADDRESS: I�C LLS1/V 1 . �L> �TL rf "(�," �'' C�.��S�.- � C1�M O WNER NAME: S�12A (�C_t.�.��t N�) .'l K.�{�'Yl Is�1 L � -� UI�S t�I'V �t2�VVtt�,,1��'( CORPORATION NAME (IF APPLICABLE): 1(W rL L�1�i2.��1 S�S I.LC'.� , MANAGER'S NAME: 5�11`2�1 �� -111�L-�� i2..�9►�tr1�3�'K i-t TEL.#:�1� -� � -(a5$C� MAILING ADDRESS:__ ( Z(d I�le i p�L� �19'fk� IM�11ZS"1�►'�S �%I t LI,�' �lA�. �Z tP4�j '' POOL CERTIFICATIONS: ' 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. l. 2. Pool operators must list a minimum 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. l. 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 Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. �.,��1 ��1��11�.�Fj�- �-� 2. -..)t 1_l4 i", � � L 7�� (f��Z 1 ��I�1M�,��`�Z �', PERSON 1N CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��'� � ��r'� l�'� N 2. 5��1 (�inS� �v 'cz � �-�rzr�v��3��- 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. ��i�YY� ��-t�l'Yl�31�Z,�� 2.�� (' 1,�1�!-t'�t��,�C�.%��hMl3f��{ 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. �.��(S(�� t�1YV1��~1 2._��'I�,� (_��.�I�`I N�Z>�i I��IYY1�'Sf�C,I-� 3. 4. ' ' RESTAURANT SEATING: TOTAL# �3a OFFICE USE �JNLY LICEN h�f�i�'F`i'�--€T'-.i�a–�Fl��t�fi4'#��_.I.ICEN�E REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 --_MOTF.I, $110 INN $55 CAMP $55 SWIMMING POOL$l lt�ea. _LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LjCENSE REQUIRED FEE P IT LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# / 0-100 SEATS $125 ��{O CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 LCOMMON VIC. $60 �2. =WHOLESALE $80 —RESID.KITCHEN $80 RETAtL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# q >25,000 sq.ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $$50 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ � `8S�C�O **x**PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** BOi�F-t.$-2.A�(L � � � �- � r � ADMINISTRATION , Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of a�y 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 ! � APPROPRIATELY IF PAID: � YES NO E i � MOTELS AND OTHER LODGING ESTABLISHMENTS � r TRANSIENT OCCUPANCY: 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. i 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 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. i POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of ; closi�g. i 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 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 Department,or from the Town's website at www.yarmouth.ma.us under Health Department, ' Downloadable Forms. ' i FROZEN DESSERTS: C � Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results i 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 establislunent is prohibited. � _ -- ----- _ _ --- -- — ' -- — - - �-- _ _ _�-- _ � __ - -- NQTICE:P�nnits 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 16, 2016. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APP OVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN. DATE: �ZI I�J� I�I SIGNATURE: �— PR1NT NAME& TITLE: ��Pl�ff�'(�,�/�Cj�-�, ��yh{';�j�Z,(..� ., � � Rev. 10/12/16 '' I a ; ; j _ -�,--.�: � -.� ' ' � The Commonwealth of Massachusetts ; _ 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 Legiblv Business/Organization Name: ��l,l.,i S � ��"�� .�Z�� Address: I �� .4� � 2�� L ��l(�u� -� Nl� bZ��0�" , City/State/Zip: � Phone #: �Q �1 `�� `�5��v ' 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. � RestaurantBax/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl. real estate,auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ 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 also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L I am an employer that is providing workers'compensation insurance for my employees. elow is the policy information. Insurance Company Name: _ Insurer's Address: City/State/Zip: Policy#or Self-ins. Lic. # Expiration Date: I 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 iof up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of i Investigations of the DIA for i surance coverage verification. I do hereby certify,under th pains and pena[ties of perjury that the information provided above is true and correct. Si ature: Date: l �� l Phone#• � ��`-��C � �� G Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Licensing 8oard 5. Selectmen's Office 6. Other Contact Person: Phone#: www.mass.gov/dia � .i"�"'1 YWKENTE-01 DRUST . ACORU� CERTIFICATE OF LIABILITY INSURANCE °"'�`"�"`°°""'"' i �"�'"� 12/14J2017 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 CQVERAGE AFFORDED BY TME POLICIE3 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 certiflcate hoider is an ADD1710NAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may requine an endorsemenk A statement on � this certiflcate does not confer ri hts to the certificate holder in lieu of such endofsement(s). � PRODUCER �T � Ro ers&Gray Insurance Agency,lnc. �►�e Fax a�Rte��a ,�,N�. : ,ew�:(877)816-2156 � South penn�s,MA o2660 �-"'"� :mail@rogers ray.com j IN8URER S AFFORDING COVERAGE NAIC# � iNsu�a:Hanover Insurance Gom an he 22292 INSURED INSURER B- i YWK Enterprises,LLC DBA Y'Ail's wcked Kitchen INSURER C: 1�76 ROUt@ ZS INSURER D: ; South Yarmouth,MA 0�664 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 ABOV�FOR THE POLICY PERIOD j INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 1 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIOtYS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR npE OP INSURANCE ��SUBR pp��Y NUMBER �CY EFF POLICY E7� V� COMMERCIAL GENERAL LIABILJTY EACH OCCURRENCE $ CLAIMS-MADE �OCCUR PARNWGE TO RENTED $ iMED EXP M one rson $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ � POIICY�� LOC pRODtSCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT i�� ANY AUTO i BODILY INJURY Per n $ OWNED SCHEWLED � . AUTOS ONLY AUTOS BODILY INJURY Per accident $ ` AUTOS ONLY AUTOS ONLY Per�a Ea�.'RdeTMi�t�GE $ 1 iUMBRELLA tJA6 OCCUR EACH OCCURRENCE EXCESS LJAB CLAIMS-MADE AGGREGATE $ DED RETENTION S ' A AND EMPLOYERS'LI�ABnILR°r X �R ER TO BE ISSUED 12N 8/2017 12/18/2018 E.L.EACN ACCIDENT $ ANY PROPRlETOWPARTNER/EXECUTIVE Y�N SOO�OOO OFFICERIMEMBER EXCLUDED? ❑N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ SOO�OOO ' o�scRi�ON Ou F OPERATIONS below 500,000 E.L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATtONS/VEHICLES(ACORD 101,A�itlonal Remarks Schadule,may be attached ff more space is requlred) Restaurant. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TNE ASOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yartnouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DfLIYERED IN 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISION3. South Yartnouth,MA 02664 AUTHORIZED REPRESENTATiVE �� ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved. 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