HomeMy WebLinkAboutApplication and WCi _
TOWN OF YARMOUTH BOARD OF AEALTH
APPLICATION FOR LICENSE/PERMIT-z0I8
*Please complete form and attach all necessary documents by �ber l5 20 7.
� Failure to do so will result in the return of your applicabon pac cet:
� ` �ESTABLISHMENT NAME: . - '�
O �'j�'. LOCATION ADDRESS:_ Q i� �Zg' . � `tcs M'��...� S-`t T'EL.#, S���3?�'- l`��
� S�, ati MAILING ADDRESS: c� � r...� C► c,�
E-MAIL ADDRESS: -1-L;r�.�� ��. y�.
1 � OWNER NAME: � q .
� N CORPORATION NAME(IF APPLICABLE): a c- .-�o�S �.��•
10�,� MANAGER'S.NAME:__ TEL.#: ��!-�t�1-�ao,-y,
`' MAILING ADDRESS: �,_�,c .Q,,-�:�.�� �►..� s 'C�� 1�..._4 �,...us . o�o;�{�,
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POOL�F ' IFICATIONS: ��
The popoel sup(j i be certitied as a Pool Operator,as required by State lx ttrase list the designated
Pool O rator s and attach a c e certification to this form..
1.
Pool operators must list a minimum of two empl �e currentlq certified in.stan 'st Aid and Community
Cardiopulmonary Resuscitation(CPR},ha ' one cerkif ed employee on premises at all tu8ea Please list the
employees below and attach copies u certifications to this form.The Health Department will not use past
years'records. You must e new copies and maintain a file at your place of business.
1. 2,
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FOOD PROTECTION MANAGERS-CERTIFICATIONS: • � �»�
All food service establishments are required to have at least one full-time employee who is certified as a Food � �:a �•°�
� Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.U00. d ��
i Please attach copies of certificafion to this application. The Health Department will not uee past years'records. -mp � ����
� You muat provid�new copies and mAintain a file at your establishmen� r-� '-� �
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PERSON IN CHARGE: � � � � � � �,�
; Each food establishment must have at least one Person In Charge(PIC)on site during hours�f operation. �
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ALLERGEN CERTIFICATIONS: � �',
All food service establishments are required to have at least one fuli-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 ttris application. The Aealth Department will not use past years'records. Yom m�st ;� (�s
{ provide aew copies aud maintain a fde at your establiehment. �;._ .>
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� HEIIviLICH CERTIFICA'1'IONS:
All food service estabiishments 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-chaking procedures below and
attach co ies of em lo ee certifications '
to this form. The Heal h De
p t partmeot will not nse ast ears record�.
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You must provide new copieg and maintain a file at yonr place of bueiness.
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3. 4.
RESTAURANT SEATING: TOTAL# ��
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OFFICE USE ONLY
LQDGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT#
i �B SSS CABIN SSS M01'EL SI10
�11d SSS —CAMP S55 —SWIWIlvIING POOL S110ea.
j =I.ODGE SSS _f'RAILERPARK SI05 =WHIRLPOOL SllOea
i FOOD SERVICE:
' LICENSE REOUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
; 0.100 SEA1'S 5125 CON1'IIJENTAL S35 NON-PROFIT S30
L»oo sEn1s asoo ��g �co�ox vic. sbo �-�7 �io�s,+t,E sao p�,. O�i'fI-6`�
� Y _�sID.��►�o � ��t—
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LJCENSE REQUIRFD FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50sq ft ESO >25,000 R. 5285 VENDING-FOOD S25
=Q3,000 sq.R 5150 =FROZEN�ESSERT S40 �I'OBACCO 5110
NAME CHANGE: S15 AMOUNT DUE = S 2�G0.OO
rr+►•pLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM+"""*
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• ADMINISTRATION �
Under Chapter 152,Se�tion 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 dces not have a Certificate of Worker's
Compensation Insurance. THE AT"TACHED STATE WORKER'S COINPENSATION 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 pernuts. PLEASE GHECK
APPROPRIATELY IF PAID:
YES� NO
M�TELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitarions of Motel ar 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 OPENIIVG:All swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Dspartment pnor to o mng. Contact the HealthDep ent to achedule the inspeMion three(3)
days prior to opening.PLEA E TE:People are NOT allowed o sTit in the pool area until the pool has been
� inspected and opened.
i POOL WA1'ER TESTIl�iG: 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. '
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POOL CLOSING:Every outdoor in ground swimming pool must be drained or wvered within seven(�c}ays of
elosing.
FOOD SERVICE �
SEASONAL FOOD SERVICE OPE1�iING: i
Alt 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 Yazmouth musC notify the Yarmouth Health Department by filing the
required Tempo Food Service Application form 72 hours prioc to the catered everrt. These forms can be
obtained at the H�th D artmen or '
ep t, from the Town s website at www.yarmouth.maus under Health Department, ,
Downloadable Forms.
� FROZEN DESSERTS:
Frozen desseTts must be tested by a State certified lab prior to openiag 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 Pemut unril the above terms have been met.
OUTSIDE CAF�S:
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 pmduct by a retail or food service establishment is protiibited.
NO'i'ICE: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 1 S,2017.
ALL R�NOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIPMENT,ETC.),MUST.BE REPORTED TO AND APPROVED BY'I'I�BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY UIRE A SITE PLAN.
DATE:_�—}-'�--(�- SIGNATURE: `
PR1NT NAME&TITLE: 1 c.�pCc. �'J.i�tx,.� � 1�-P `Y�t�Sets.G-�
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�'\ The CommonweaLth of Massachusetts
Department of Industrial Accidents
, 1 Congress Street,Suife 1 DO
a
Boston,MA 021Y4 20X7
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Generai Businesses.
TO BE FILED WTTH THE PERMITI'ING AUTHORITY.
Applicant Information Please Print Legiblv
Business/Organization Name:____�A��.. �,,..��
Address: Q�-� �-S� � a``f"o M�l a.�� ��� , .
City/Sta.te/Zip: �. � Phone#: ��-�- '��Sr-- i 1�{ l
Are you an employer?Check the appropriate bo�: Business Type(required):
1.�I am a employer witt���employees(full and/ 5. ❑Retail
or part time).* �y 6. �estaurantlBar/Eating Fstablishment
2.❑ I am a sole proprietor or partaership and have no �. �p�ce and/or Sa1es(incl.real estate,auto,etc.)
' employees worldng for me in any capacity.
' [No workers'comp.�nc„rance 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 10.0 Manufacturing
no employees. [No workers'comp.+nc„ra.,ce required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.Q Health Care
with no employees.[No workers'comp.�ncnran�e req.] 12.0 Other
� "Any applicent that chocks box#1 must also fill out the section below showing their worke�s'compeosation policy infoimatiaa
*"If the corporate officers have exempted themselves,but�e corporation has other empioyees,a workecs'compensation policy is requined aad sueh an
organization should check box#1.
� 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: �,�.,.��,.r �� ��..�� �'�''r-� '�+�. �r� ,
Insurer's Address: �j�� ��.ti��:,,..-.., ��
City/State/'Lip: h/��i r-�S-��.�. �_,, ��"1 �t:
Policy#or Self-ins.Lic.# `'���"'a- �"�3�,t�`� '"� Expiration Date: fo e; � � �
Aitach a copy of the workers'compensation policy declaration page(showing the policy number a d e7cp� ation date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the irnposition of criminal penal6es 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 tl�is sta.tement may be forwazded to the Office of
Investigations of the DIA for insurance coverage verifica.tion.
I do hereby certify under the pains and penalties of perjury thaf the information provided above is true and correct
Si � Date: 1 —�a—1
Phone#: �''�l—' �{�1--' 1�.�,€�
O,fj''zcial use only. Do not write in this area,to be completed by city or town of,ficia[
City or Town: PermiflLicense#
Issuing Authority(circie one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selecfinen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
`'�rw� SPECBRA-01 E
ACQRUY
�.,,_..--� CERTIFICATE OF LIABIUTY INSURANCE DATE�MM/DOlYWY)
06/27/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATH pOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TNIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certtficate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
if SUBROGATION IS WAIVED, subject to the tenns and conditions of the policy,certain policies may require an endorsement. A statement on
this ceKificate does not confer ri hts to the certificate holder tn Ileu of such endorsemen s.
PRODUCER C ACT
Krauter�Company PHONE
13b0 Avenue of the Americas ac No,e�e:1 (212)596-3400 �,N,;1(212)596-3460
18th Floor
New Yo�k,NY 10019
INSURE S AFFOROINCi COVERA(iE NAIC#
wsur�Ra:United States Fire Insurance Com an 21113
INSURED INSURER B:PII FIt11 II1SU1'dI1C@ COfl'1 an
Specialty Brands Holdings,LLC wsuaeRc:XL Catlin
600 Providence Highway INSURERD:
Dedham,MA 02026
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. NOTIMTHSTANDING 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 HEREINISSUBJECTTOALLTHETERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS.
INSR TypE OF INSURANCE A��SUBR POUCY EFF POUCY EXP
POUCYNUMBER u�
A X COMMERCIAL GENERAL LIABILITY 'I�OOO�OOO
EACH OCCURRENCE S
CLAIMS-MADE a occuR 543-217454-1 06/30/2Q17 �6/30/2018 �� ETORENTEO $ 1,000,000
M 0 EXP one rson
P RSONALBADVINJ RY ��OOO,OOO
GEN'l AGORE ATE LIMIT APPUES PER: GEN RAL AOOR GATE a �O,OOO,OOO
X POLICY���� ��p� PR T -COMP/OPACG Z,OOO,OOO
OTHER: IIiCIUfI@CI
B AUTOMOBILE UABIUTY COMBINEO SINGLE IIMiT S 'I,OOO,OOO
S
nr�r nuro CSC-00001002881 06/30/2017 06/30/2018
OWNE� S��ESULED BODIIYINJURY Pet S
AUTOS ONLY x O 80DILY INJURY PeraecMent S
X A��S ONLY X AUTO�O�Y �2eOPEe�R 8�AMAGE S
C X UMBRELLA LIAB X O�CUR 5
EACH OCCURRENCE g 25,000,000
El(CESSlUlB CIAIMS•MADE US00079103LI17A 06/$0/201� 06/30/2018 A REGATE S 25��0�,0��
DED X RETENTION S �O�OOO
A WORKERS COMpENSAiION PER p7� s
AND EMPLOYERS'LIABILITY X
ANYPROPRIETOR/PARTNEWEXECUTIVE Y�N 08-731603-4 Os/30/20�� 06/30/2078 ��000,00�
FF ER/MEMB�EXCLUDED9 �N N!A E.L.EACH A CIDENT f
nory in N 1 000 000
I(yes desc�ibe under .L DISEASE-EA EMPI. Y � �
DESGRIPTION OF OPERATIONS below E.L DISEASE-POUCY LIMIT S ��OOO�OOO
A Ltquor Aggregate 543-217454-1 O6/30/2017 06l30/2018 Aggregate 2,000,000
A Liquor Liabtlity 543-217454-1 06f30l2017 06l30l2018 Common Cause 7,000,000
DESCRiPT1pN OF OpERATIONS/LOCATIONS/VEHICLES (ACORD 701,AddRional RemaAcs Schadule,mey be attachad H more apaca Is requ�red)
CERTIFICATE HOLDER CANCELLATION
' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Evidence of Insurance 'fHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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ACORD 25(2016/03) O 7988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
�.■� AGENCY CUSTOMER ID:SPECBRA-01 MERMY1
� 7 LOC#: 1
ACOR[�a
L..../ ADDITIONAL REMARKS SCHEDULE Pa�e. � ot �
AGENCY NAMEDINSUREO
rauter&Company Specialty Brands Holdings,LLC
600 Providence HIghway
POLICY NUMBER Dedham,MA 02026
EE PAGE 1
CARRIER NAIC COOE
EE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE P E
AODITIONAL REMARKS
THIS ADOITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: ACORD 25 FORM TITLE: CertiRcate of Uabilky Msurance
The followtng are included as Additional Named Insured:
Spectalty Brands Holdings,LLC
PGHC Holdings,Inc.
Papa Gino's Holdings Corp.
Papa Gino's,Inc.
Papa Gino's F�anchising Corporation
Delops,Inc.
D'Angelo Sandwich Shops,Inc.
Progressive Food,Inc.
D'Angelo Franchising Corporation
South Point Hospitality,Inc.
Project Grili
Project Grili II
Pap Gino's/D'Angelo Card Services,inc.
D'Angelo Sandwich Shops Advertising Fund,Inc.
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ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rlghts reserved.
The ACORD name and logo are registered marks of ACORD