The URL can be used to link to this page

Home My WebLink AboutApplication and WC �� TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOYt LIC�NSE/PERMIT-2018 . " "Please complete form and attach all necessary documents by December IS 2017. Failure to do so will result in the return of your applicahon pac et. ESTABLISHMENT NAME: � � LOGATION ADDRESS: �r TEL.#: S — 9 --a t�33 MAILING ADDRESS: �8 Tacomr LJ a4 l�!� �.av� R.� e�.84�'3. E-MAIL ADDRESS: S 4�(�A h�ta�,�nnf�i o�t1.9/'�D�tA. C O� OWNER NAME: CORPORATION NAME�IF APPLICAB E): ' MANAGER'S NAME: o TEL.#: � MAILING ADDRESS: J" �' m2 r�� lP j' Da�� POOL CERTIFICATIONS: The poot supervisor must be certifed as a Poal Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certification to this form. 1. �0. 1AS�� 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 aew copies and maintain a file at your place of business. , � p � 1. �a��(e��SP// 2. V��M0. �/'Z91,�r1 r./S—�l,/1�.r � � C7 3. 4. � A m � � ..� < FOOD PROTECTION MANAGERS-CERTIFICATIONS: � `� rn All food service establishments are required to have at least one full-time employee who is certified as a Food � � 0 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 Heaith Department will not use past years'records. You must provide new copies and maintain a file at your establishment. ., 1. 2. PERSQN IN CHARGE: '� Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. � l. 2. � � .� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-tune employee who has Allergen certification, � , : as defined in the State Sanitary Code for Food Service E�tablishments,105 GMR 590.009(G)(3)(a). Please attach ; copies o f certi f ication to t his app lication. T he Hea lt h Department wi l l not use past years'recor ds. You must �':�� provide new copies and rnaintain a fite at your establishment. i. 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 anri-choking procedures below and attach copies of employee certifications to this form. The Heaith 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. !�L-(�-�'�'l37�'Q3 RESTAURANT SEATING: TOTAL# c�7 BoiKP—t�=fQ3q�aj o��HSP-�S'!Q�Q�Q3 OFFICE USE ONLY ��P rs.��r.-o3 LODGING: LICENSE REQUIRED FEE PERMiT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P T# B&B S55 CABIN S55 MOTEL 5110 INN S55 CAMP S55 SWiMMING POOL$110ea. ... r�}�O�{0 =LODGE S55 _TRAILER PARK S1U5 _ _WHIRLPOOL SI IOea FOOD SERVICE: LICENSE RE UIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQ UIRED FEE PERMIT# 0-100 SEA�S $125 _.CONTINENTAL $35 NON-PROPIT S30 >I00 SEATS 5200 �COMMON VIG. S60 —WHOLESALE SSO —RESID.KITCHEN S80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�RMIT# LICENSE REQUIRED FEE PERMIT t� <50 sq.ft. S50 >25,OOU sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.ft. 5150 _FROZEN DESSERT�40 _TdBACGO 5110 NAME CHANGE: $IS AMOUNT DUE _ $��f�d• OO '**"•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM�"**• ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmauth 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 GERT.OF INSURANCE ATTACHED �I OR WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED Town of Yannouth ta�ces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES�� NO MOTELS AND OTHER LODGING ESTABLISHMENTS 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 a�gregate 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 aze NOT allowed to sit in the paol 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 quarteriy thereafter. POOL CLOSING:Every outdoor in ground swimming pool must be drained or covered within seven(7)days vf clasing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please cantact 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 Yannouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be abtained at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadabie 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 ta do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: 4utside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOKING: 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(3)AND REQUIRED FEE(S)BY DECEMBER 15,2017. ALL REN�VATIONS TO ANY FOOD ESTABLISHMENT, MOT'EL R POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REFORTED TO AND APPROVED THE BOARD OF HEALTH PRIOR TO COMMENC E T. RENOVATIONS IvIAY REQUI S LAN. Da�: ll Zt 1 SIGNATURE: PRINT NAME&TITLE: �]�piAliO /'1'1�G�o l�L� �/�O Rev.10/12/17 1 � � ae p� CERTIFICATE OF LIABILITY INSUFtANCE °�TEt"'�"'°°"'n"" �...--� ��.�ai�a�� 7H1S GERTIFIGATE IS ISSUED AS A MATTER dF INFORMATION ONLY AND CONFERS N� RIOHTS UPQN TNE�ERTIFIGI0.TE H�LdfR.THIS CERTIFICATE D�ES NOT AFFIRMATIVELY OR NEaATIVELY Ah1END, EXTEND OR ALTER THE QCSYERAtiE AFFORDED BY THE POLlCIES ' BELOW. THIS CfRT(FICATE OF INSURANCE OOES NOT CONSTITUTE A CBNTRACT BETWEfN THE tSSUINt3 INSURER(5),, AtiTHQR1ZED REFRESENTATIVE OR PRODUCER,AND THE GERTIFICATE HOI.DER. IMPORTANT: If3he certificate holder is a�ADDiTiONAL INSURED,the poticy(ies)must be endorsed. ff SUBROOATlON IS WAtVE�,subject to the t+erms and eonditions ofthe policy,certain policies may require<an endursement. A statementan this certi�cefe does not confer'rights to the certi�cate holder in lieu of such endarsement s. PRQDUCER CONTA N E: JENNY FERREIRA GENATT V LLC PHONE .516-869-866B F� .516-70�5-332'7 3333 NEW HYDE PARK RD BUITE'4Q0. � � .jennyf(dlgenatt.com ' NEW HYDE PAI�K NY 11042 iNsuRE s nFr-o�ouwcuvEw►c� raa�c�- iNsu�an:Zurich North America i 1NSU�2ED NEWPHOTE INsuRERs. Newport Fiotgl Group L�C,ETAL iNsuRER<r: �8 Jacome Way iNsuReR o: � Middletown,RI 02842 INSURER E: , INSU ER F� I COVERA�ES CERTIFIGATE NUMBER:1282366847 R t ION U BER� THIS IS TO CER7IFY THAT THE POGCIES OF INSURANCE LISTED BEIQW HAVE BEEN ISSUED TO THE INSURED NAMED RBC3VE 6DR THE POUCY PERIOD WOIGATED: NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDlTION OF ANY CONTRAGT OR OTHER DOCUMENT WRH RESPECT TO WH(CH THIS CERTIFIGATE"MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 7HE POUGIES DESCRIBED'HEREItJ f& SUBJECT TO ALL THE TERMS, EXGLUSIONS ANLI Ct2NDITIdNS OF SUGH POLICIES.LIMITS SHOWN MAY HAYE BEEN REDUCED BY PAID CLAIMS. I I 3 TyPE OF INSURANCE' I POLICY NUMBER P CY F uMRS C6MMERCIAL GENERAL LIABILITY EACH 4CCURFtENGE $ ClA1MS-MADE �OCCUR y MEQE3CF' a» 3 PERSONAL&A6V ULlUR`l 3 GEN'L AGGREGATE UMIi APPCIES PER: Li6NERAL AGGREGATE $ ROIIGY�E�7 �LOG PRODUCTS-CQf�iP/OP AGG $ OTHER: $ ' AUTOMOBILE LIABILITY Ea S , ANYAUT4 :BOOILYIN.IURY(PerPerwn) S ' AUTUSN�� A TOSUCED 90DILYINJURY{Perasddant) $ NON-OWNED . HIRED AUT6S A�p,�r .��.a�rn- . $ � � UM9RELLA LIAB OCCUR EACH OCCURf�NCE :$ : EXCES8LIA6 CWMS-MADE RtiGREC3ATE S DED RETENTIONS $ q IMQRKERS COMPENSATION V1IC0140U8003 11/15/2017 11l15�2Q18 AND EMPLOYERS'LfNBILtTY Y!N AhFY P'ROPRIETt'SF3/PARTNER7EXECUTIVE ❑ N/A EL,EAGH ACCIDENT S.1,a00 DQ0 OFFlCER/MEMBEREXCLUDE07 lMland�toTY►�Ny1 E.L:D1SEqSE-EAEMPLfkYE #1U�f1�0' DES�RI�PT�10 OF�tWERATiCNJS below E.L.DISEASE.PBLICY LIMIT 51 00D 00(1 DESCRIPTION OF OPERATIONS/LOCATIQNS!VEHICLES{ACORD 101,Addkional Remarb Scheduta,may be atteched if more apece is requiwdJ AS ftESPEGTS: 1)HRRBORVIEW HOTEL INVESTORS'LLC',213 OCEAN STREET;HYANNIS MA 02601 2)NEW HRVEN HOTEL,229 GEORGE STREET LLG, 229 GEORGE STREET,NEW'HAVEN:CT 06510 3)BRISTQL HARBdR(NN,BHI LLG,259 THAMES,BRISTOL RI 02809 4)NEINPORT BEACH HOTEL f�ND SUITIES,FIRST BEACH LLC, 1 �20 WAUE AVENUE,MIDQLETaWN Rf 02842 5)WN QN[THE SQUARE,LLC,40 NORTH MAIN STREET,FALMOUTH MA 02540 See Attached:.. CERTIFIGATE HOLDER CANCELLATION 30 DAYS' SHOULQ ANY OF THE ABOVE DESG�BED Pt3L[CIES BE CANCEILED BEFORE EVIDENCE INSURANCE ONLY THE EXPIR10.7ION DATE` THEffEOF, NOTtCE WILL BE DELIVERED IN ACCORDANGE WITH THE Pt7�LICY PROUiS�TIS. AUTNORIZED REPRESHNTATNE � �1988-2014 ACt3RD CQRPQRATMON. All[ights reserved. ACORQ 25(2014l01) The ACORD nameand logo are registered marks of AGt)RD , AGENCY GU5T4MER Id:NEWPHdTE �oc#: ''�'�'�� ADDITIONAL REMARKS SCHEQULE Paa� � �f 1: AGENGY NkMEDINBURED GENATT V LLG Newport Hote!Group LLC,ET/�L aoucr NUMaeR 28 Jacome Way Midd[etown,RI 02842 CARRfER�� NAIGC4DE - � � �EFFECTIVE�DATEt � �� . � ADDITIONA�REMARKS THIS:ADDITIONAL REMARKS�QRM i5 A,SCHEDULE TO AGORD FORM, FORM MLMBER: 2� FORM TITLE: CERTIFICATE OF LIABICITY INSClRANGE 6)N4�RTH G4NWAY GRAND HOTEL,JONDI'�UG LLC, 72 GOMMON GT,N4RTH GONWR'Y NH 03860 7)O�EAN MtST HaTEL,BROI LLC, 73&-97 SQUTH SHORE DRNE,SOUTH YARMQUTH MA p�664 8j GA HYANNIS LLC,235�CEAN STREET,HYANNIS MA 02601 9j'BRCJI LLC D/B/A BASS ROCKS OCEAN INN, 107& 10$ATLANTIC AVENUE,GLQUCESTER MA j _ � � i , � i M i i i I i i � � ACL?RD 101(2008/01) (�7 20dS AGORD�QRPQRAT4QN. All�ights reserved. The ACORD name and logo are registered marks of ACORD