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Home My WebLink AboutApplication and WC �y� TOWN aF YARMOUTH SOARD OF HEALTH APPLICATION FOR LICENSE/PERNIIT-2018 *Please complete form and attach a�l necessary documents by e i/ r S 2017. Failure to do so will result in�the retutn of your applicahon pac cet "� ESTABLIS�IMENT NAME: �— � • � LOCATION ADDRESS: S 1' • L.#: S O — �' y,33� � MAII,ING ADDRESS: T . �-M.aII.ADDRESS: 1�4 YJ C D l; Ut Ma i4• (�� OWNER NAME: v CORPORATION NAME(IF PLICABLE}: 1�+ �a�r��°s rt�: �1A� IM�K�h �L.#: - '1 - 1�Q,S� I 1vTAILING ADDRESS: N • f Z��3 � POOL CERTIFICATIONS: The pool supervisor mus certified as a Pool Opera�or,ns required by Inw. Please iist the designated � Fool Operator(s)and a py of the certification to tlus form. �• � 1, 2. Pool operators must list a ' um of two empioyees currenuy certined in s'tanitard rirs't p,id ana i;ommumi'ry = O � � Cardio ulmo Resuscitahon CPR, one certified em loyee onpreu u'ses at alt times. Please list the �i c7 �w� � P �'Y � ) havmg p employees below anci attach copies of�eir certifications to this form.The Health Department will not use past D � � , years'records. Yoa must prov�de copies and maintain$51e�t your place of businesa L � � � � � 1, 2. �� rv '�^ ' 4. • -o � � ' �• --i -� � i FOOD PROTEC'TION MANAGERS-�CERTIFICATIOWS: ! .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.Q00. � Ple�s��h�►pies of c,�rtificat�on�this application.,The Health Depxrtment will not nse past pears'r�ords. � Yoa mnst provide new copies and maintain a 51e at yonr establishmenk ��+� � �. -r�y �"ort�5o� 2. ��c.� �-� TuM�3�=� �� PERSON IN CHARCiE: � I Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. ; , - �_ bl,to�l, � '� ! `� ' � ; ! ALLERGEN CERTIFICATIONS: All food service estahlishments are required to have at Ieast one full-time employ�who has Allergen certification; `i,, �? Ks�fi.n�:n the State Sa�itary�'e�e fdr Food C�ce Bs±ablissmsnts,l QS GMR 544.949(G)(3�(a?. Ple�.se a�twach ! copies of certificarion to this application. The Health Department will not use paat years'records: You must j provide new copies and maintain a file at your establisLment. � , 2 � � ; .. , HEIMLTGH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Ma�neuver 4n th�premises at all��: Pl�se li�yo�r�Q�oy�trained in anti-cholung procedures below and attach copies of employee certifications to this form. The I�ealth Department will not use past years'records. You must vide new piea and maintain a ffte at yonr place of bnsiness. 1, T� �� 2. ��I�v C,T�� 3, --� 4. RESTAURANT SEATING: TOTAL# . � OFFICE USE ONLY LODGIIVG: LfCENSE REQUIRED FEE PERivIIT# LICENSE REQUIREII� FEE PERMIT# LICENSE REQUIItED FEE PERMIT.# BBcB $55 CABIN S55 MOTEL 5110 —INN $55 GAMP ' S34 _SWIMMINO POOL S110ea. I.ODGE �53 TRA.�ERFARK $iM _.,1b�.'-:[RLPOOL 5170�. , FOOD SLRVICE: LICENSE REQUIRED FEE LICENSE REQCJIREiI� FEE PF.RMIT# LICENSE REQUIRED FEE PERMI'f# � �0-iQ0 SEA1'S 5125 � 3Q CONTINENCAL '. $35 NON-PROFff S30 >100 SEATS 5200 :,LCOMMON VIC ' $60 �� —WHOLESALE S80 — —:LE^s:B.K.*:CHEN S80 RETAIL SERVTCE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIREI7 FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50sq ft. S50 ' >25 000sq ft. 5285 VENDWG-FOOD S25 ;Q5,000 sq.ft. $150 _'FRdZEN DESSSRT S40 _TOBACCO $110 r�inMEGii.�riGE: Sis Ai'l+IQLTI�TDUE � S !$v`.C3Q i i •**"*PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM'"••* � , Q�o�F—I�-6�OC3-0�( ADMINIST'RATION Under Chapter 152,S�tion 25C,Subsection 6,the Town iof Yarmouth is now required to hold issuance or renewat of any license or permit to operate a business if a persaln or company dces not have a Certificate of Worker's Compensation tnsurance. THE ATTACHED STA'�"E WORKER'S COMPENSATION INSURANCE • AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR CERT.OF INSURAN�E ATTACHED OR` � WORKER'S COMI'.AFFIDAVIT�IGNED AND ATTACHED Town of Yarmouth taxes and liens must ire paid 'or to�enewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IP PAID: YES NO MOTELS AND OTHER LODGING ESTABLISAMENTS �ITRANSIENT OCCITPANCY: For purposes of the limi�ations of Motei or Hotel use,Transient occupancy shall be � l.�nited to Lh�±..��o.�.*y and�.hc�+t..�rm�cc�.�^ancy,or�in.�rrily and e�ar+w�a.rily assu�ia+x��ri+.h motel2nd het�l use, � Transient occup�ts must have and lie able to demonstrate that they maintain a principal place of residence � elsewhere.Transient occupancy shall generally refer ta continuaus occupancy of not more than thirty(30)days,aad � an aggregate of not more than ninety(94)days within any six(6)month period. Use of a guest unit as a z+esidence or . dwelling unit shall not be considerexi transient Occupaz}cy that is subject to the collection of Roam Oceupancy Excise,as defined in M.G.L.c.b4G oc 830 CMR 64G,as amended>shall generally be considered Transient. I POOLS � � POOL OPENII�TG:All swimming,wading and whirlpools which have been closed for the season must be inspected � by the Health Department prior to operung. Contact the�Iealth Ikpartment to schednle the inspechon three(3) � days prior to opemng.PLEASE NOT'E:People are NOTT allowed to sit in the pool area until t�e p�l has been � inspectea and opened � ' POOL WATER TESTING: The water must be tested Sor pseudomonas,total coliform and standard plate count ; by a State certified lab,and submitted to the Health Departmcnt three(3)days prior to opening,and quarterly thbreafter. � POOL CLOSTNG:Every outdoor in ground swimming pool must be drained or covered within seven('1}days of I closing. i i FOOD SERVICE � SEAS�NAL FOOD SER'V�CE OPENING: � All food service establishments must be inspected by the Health Depaztment prior to opening. Please cortact the � Health Department to schedule the inspection three(3)days prior to opening. ; CATERING POLICY: � Anyone who caters wittun the Town of Yarmouth must notify the Yarmouth Health Depardnent 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 firom the Town's website at www.varmouth.maus under Health Department, Downloadable Forms. FROZEN DESSERTS: ' ' �rozen desserts must be tested bp a State certified lab priar to opening and monthly thereafter,with samgle results submitted to the Health Deparlment. Failure to do so w�ll result m the suspension or revocarion of your Fmzen � Dessert Permit until the above tarms have been met. OUTSIDE CAF�S: , Outside caf�{i.e.,autdo�r seating witti waiter/�vaitress seivice),mus2�av�griar apprav�l fram the Baartl of Health. OUTDOOR COOI�NG: Outdoor cooking,preparation,or displsy of any food product by a retail or food service establishment is proWbited. NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILIT'Y TO RETURN TI�COMPLETED RENEWAL APPLICA'TION(S)AND REQUIRED FEE(S)BY DECEMBBR 15,2017. ALL RENOVATTONS TO ANY FOOD ESTABLISI-ItVIENT, MOTEL OR POOL (i.e., PAIlVTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO ANI� PROVED BY TI�BOARD OF HBALTH PRIOR TO COMMENCEMENT. RENOVAT[ONS STTE PLAN. , ^ DATE: EU'2.1' 20�} SIGNATURE: �, FRINT NAME&TITLE:_ 1�L�YIM,t/IV✓� �U`i �.iaivn � � t��C� ►�e �� o� �d �.�t-� ��-'F4� t ACORD� °^,��"""°°"n,�'', �� CERTIFICATE OF LIABILITY INSURANCE osio,rzo,� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY APID CONFERS NO RIGHTS UPON THE CER7IFICATE HOLDER.THIS CERTiFICATE DOES NOT AFFIRfWATIVELY 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(les)must be endorsed. if SUBROGATION IS WANED,subJect to the terms and conditions of the policy,certain policies may repuire an endorsement A statement on this certificate does not eonfer rights to the certificate holder in lieu of such endorseme s. r�oo�R Benson Young&Downs Ins CONTA� Kathy Jones 565A Route 28 PHONE (508)432-1478 F'� .(508)430-1532 P O Box 158 �� k�thyjories�byandd.com Harwich Port MA 02646-0158 � FF � # ,Hartford Fire Insurance Company 19682 iNsu�o .HaspitaUty Mutual Insurance Company Raymond C.Roy and RCR Management Inc ��'s i 540 Main Street,Rte 28 West Yarmouth MA 02673- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS�S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POIiCY PERIOD INDICATED. N071MTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT UNTH RESPECT TO WHICH THIS �c�i i�1Cia i c ivwi Sc i�aucu i�R iw+r�c�i i„iiJ, i nc iidSui'wF1Cc fvFi�iiCcu o i i ric �uLiCica ucS�RiScu^ I'7CR�IIV is Sua.ici,i i u Ai.i.i ri�i c'ntrvf�, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS. �� TYPE OF INSURANCE �DL SUBR POLICY EFF POLICY EXP UMITS Cq�IMERCIAL GENBRAL LU&LITY EACH OCCURRENCE CWMS-MADE �OCCUR DAMAGE TO RENTED = MED EXP one rsai S PERSONAL 8 ADV INJURY S GEN`L AGGREGATE LihAiT A�PLiES PER: GENEftAL AGGRE�,AfiE 3 POLICY❑JEC7 �LOC PRODUCTS-COAAP/OP A G S AUTOMOBILE W18N.ITY CONABINED SINGLE IIMIT $ ANY AUTO BO�ILY INJURY(Par person) E ALl OWNED SCHEDULED BODILY INJURY(Per eccidenU S IR D AUTOS N N-00�IED PROPERTY�MAGE _ AUTOS S UII�RELLA IJAB p�CUR EACH OCCURRENCE EXCESS LlAB CLAIMS-MADE AGGREGATE S 'i I, /� WORKERS COMPENSATION O8WECKH2770 5/18t2016 5/18/2017 X �R orr+. 'i AND EMPLOYERS'W&L.I7'Y YYYlllNNN � ANY PROPRIETORfPARTNERIF�(ECUTIVE � E.L EACH ACCIDENT 1 OO,OOO i OFFICER/MEMBER EXCLUDEDT N�� 'I OO,OOO (Alandatory In NN) E.L DISEASE-EA EMPLOYEE S It ea,desatbe under 500,000 EL 01 E-PO Y IMIT B Liquor liability 00035612L1 524/2016 4/2017 Per Person 500,000 PerOtxurence 1,000,000 Aggregate 1,000,000 pESCRIPT1pN OF OPERATIONS I LOCATIONS I VENICLES(ACORD 101 Additiaul R�rics ScMdub,ma b�atheMd H mon sqw is nquin� Seasonal Restaurarrt located at 540 Main Street(Route�18),West Yarmouth,MA 02673. i Workers Compensation c,overage is not provided for Ramond C.Roy. ; � � CERTIFICATE HOLDER CANCELLATION AI 059964 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF,NOTICE N11LL BE DELNERED IN i Licensing Dept ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 28 South Yarmouth MA 02664- �TH�FtlZED REPRESENTATIVE �� _ /`�►-J i :r�� /�•�--�� d! �1988-2014 ACORD CORPORATION. AA rights reserved. ACORD 25(2014t01� The ACORD name and logo are registered marks of ACORD ! � 10/31/2017 08_35 l349-6311 430-1532 BYANDD Heather Rogers-�Town of Yarmouth 2/2 ,/�, A�Q� CERTIFICATE OF LIABILITY INSURANCE °p�rM�°°"rvY, , 1 0/31 201 7 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE HOIDER: THIS I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIYELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES , BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSWING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERIIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. IT SWBROGATION IS WAIWED,subject to the terms and conditions oithe policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certiflcate holder in lieu of such endorsemant(s. PRooucER genson Young&Downs Ins coNTncr 1(ethy Jones 565A Route 28 P�� . (508)432-1478 I FAx (508)430-1532 P O Box 158 E�'^� kathyjones�byandd.com ' Harwich Port MA OZE4E-O'IS8 INSIAtERS AFFORDING COVERAGE Narc� � E .Hartfwd Fire Insurance�ompany 19682 iNsu�o Raymond C. Roy and RCR Management Inc � u� c: Salty's 540 Main Street,Rte 28 in�su�ER o: West Yarmouth MA OZE�3- INSURER E: ' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; THIS IS TO CERTIFYTHAT THE POUGES OF INSURdNCE LISTED 9ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WNICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN,THE INSURANCE AFPORDED BY THE POLICIES DESCRIBED HEREIN IS SWBJECT TO ALL THE TERMS, EXCIUStONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOIMV MAY HAVE BEEN REDUCED BY PAID CLAIMS. �N� � �� pp�,g� POLICY EfF POLICY EXP LIMIlS TYPE OFINSURANCE POL COMMERCIAL GENERALLIABIIITY EACH OCCURRENCE $ �� DAMAGE TO RENTEG A CLPJMSMADE �OC�UR ' MED xP Anv one erson � FERSONAL&A6V INJUGY $ � 6EV'L AGGREGAIE LIPAIT APPL'��ESPcR: GENERHL AGGREGAT=. .. E PqUCY' �PR� �LOC FRODUCTS�COtdPlOP.4GG $ JECT S i AUTOMOBILE IIABILITY COPf�BWED SINGLE LIMIT $ � NJY AUTO � BOQ�LY INJURY(Per person) $ � . � 0'NN=G SCHEDULED BODILY WJURY(Per acc�denq $ AU�OSONLY AUTOS HIRED . NON-OWNED PROPERTY DArnaGE � � � � AII?C�SONLY AlJr05ONLY $ UMBRELLA LIAB C�UR EACH OLCURFENCE $ EXCESS LlAB CLAIMSMAD`�` AGUREGATE $ D. . R= EMI. N $� q WOR1(ERS COMPENSATION 08WECKH2770 5/18/2017 5/18/2018 X �R oTr+ AND EMPlOY�tS'LIA8ILITY 1 OO,OOO . MJY F'RbPRIETGRiPART�ER/E:dECUT�'dE Y� NIA E.L.EHCH ACCiDENT . S . oFFIC�t,n�EMB�rz�cauoE�r 100,000 (MandatoryinNFQ E.I.qSEASE-EAEMPLOYEE $ t yes.d2saibe under EL.pSEASE-POLICv Utv�R g 500,000 � �ES RIFTI�N P RATI NSb I � DESCPoPTION OF OPERATIONSI LOCATIONS!VEHICLES (ACORD 101 Additional Remarks SchedWe,ma be attached if more space is required) � � Seasonal Restaurant located at 540 Main 5treet(Route�8),West Yarmouth,MA 02�73. — � Workets Compensation coverage is not provided fw Ramond C. Roy. �'��''�� ac� � � 20» EA�TH D�PT. CERTIFICATE HOLDER CANCELLATION AI 008455 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Tov�n ofYarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Board of Nealth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Rte 29 South Yarmouth MA 02664- A��Po�DREPRESENTATIVE , • ��` O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks oi ACORD , � l0/31/2017 08_35 �349-6311 �30-1532 BYANDD Heather Rogers->Tocvn of Yarmouth 1/2 � I y� 565A Route 28, PO Box 158 &Dowr�s Hanrvich Port, MA 02646 insurance Agenc , tnc. 508-432-1256 fax 508-430-1532 � Senring all your insurance need� I � FAX TRANSMISSION Date: October 31, 2017 � To: Town of Yarmouth � 15087603472 Company: Healfh Department From: Heather Rogers Pages: 2 (including this sheet) RCR Management Inc Attached, please find the cerfificate of workers' compensation in regards to our above insured. Thank you!