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HomeMy WebLinkAboutApplication and WC ARA ' TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 1.5.2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER l5"'. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: P ffik`►1 rlit �(J�i[dAorTAX ID: LOCATION ADDRESS: 16(0,.44(/y1 S [4rm 4k, /' TEL.#: .2j 3 9 { d-)-f)- MAILING ADDRESS: 34/rG E-MAIL ADDRESS: L%6V . C61--(11 ii h t/J0/h it fj,f ol. t If iii OWNER NAME: CORPORATION NAME(IF APPLICABLE): - ,Lt j / l L ( h /-4- MANAGER'S NAME: )4 4J fti(Is 1 ' L.#: ci` 2- r l , . f MAILING ADDRESS: j�(( l j ,411?d 1�yq h n ns 1 /I4 o 'a I POOL CERTIFICATIONS: = z ,o The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated M O ljil Pool Operator(s)and attach a copy of the certification to this form. r- , -1 1. 2. _ la„ n Pool operators must list a minimum of two employees currently certified in standard First Aid and Community n1, Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the __1 ao 0 employees below and attach copies of their certifications to this form.The Health Department will not use past yearsrecords. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. 4 r ' FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food }v 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. I-)- You must rovide new co ies and maintain a file at your establish ent. 1. IN(I ((� 54( kx ; 2. �-�k. o V �G I f 714 ,vJ s PERSON IN CHARGE: g', Each food establishment must have at least one Person In Charge(A1h / on site during/ hoursofoperation. 1. Ovid A 1( 2. K�. I9 tlJ l ALLERGEN CERTIFICATIONS: "b 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 o provide new copies and tain a file at your establishment. n 1. (`Ie( iLT iG� 2. I,k Du1,-)OC I 'n HEIMLICH CERTIFICATIONS: 4. 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 1 0 attach copies of employee certifications to this form. The Health Department will not use past years'records. W You must provide new copies and maintain a file at your place of business. 1. t✓j I(,'4 m 1441111 2. C k 12/t . L( -4 3. Nu* (,��ifrrt'rmh 4. If4i hti// RESTAURANT SEATING: TOTAL# gOi 0/ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 =SWIMMING POOL$110ea i LODGE $55 =TRAILER PARK $105 _WHIRLPOOL $110ea. j FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 ��� � CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 4 �t__`t/* -1—COMMON VIC. $60q =WHOLESALE $80 1 _RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 '.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 =<25,I I I sq.ft. $150 =FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 2'O.00 *****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 pri 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 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 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. 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: 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. 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 m 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 COOKING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered an expired license,and the tobacco license cap is reduced. 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 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLIS I I NT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND/'PRO i :Y THE BOARD OF HEALTH PRIOR TO COMME CE 1 NT. RENOVATIONS MAY • ♦ A SN. DATE: i SIGNATURE: PRINT NAME& 1T1 LE: ),--6(//1 { cf l / f h 4 'Jou Rev.10/23/18 ^___....-.4" CATAHOS-01 APELL ACORDr DATE(MM/DD/YYYY) 4011.... CERTIFICATE OF LIABILITY INSURANCE 01/03/2018 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, 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 Rogers&Gray Insurance Agency,Inc. PHONEI FAX 816-2156 434 Rte 134 (A/C,No,Ext): (A/C,No):(877) South Dennis,MA 02660 aooBlESS:mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Massachusetts Retail Merchants WCSIG,Inc.00000 INSURED INSURER B: Catania Hospitality Group,Inc.,ETAL INSURER C: 141 Falmouth Road INSURER D: Hyannis,MA 02601 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. 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYYIIMM/DDIYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY (EOc Ma accl,iden SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY _ AUOTOS ONLY PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS ND EMPLOYERS'LIABILITY X STATUTE EERH Y/N 014005032239117 01/01/2018 01/01/2019 500,000 ONY EXCLUDED ECUTIVE N N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 141 Falmouth Road Hyannis,MA 149-151 Main Street Sandwich,MA 25 Summer Street Plymouth,MA 151 Main Street Weymouth,MA 1225 lyannough Road Hyannis,MA 1196-1198 Main Street South Yarmouth,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Informational Purposes OnlyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED 'REPRESENTATIVE 'EP RRE SENTATI V E I '�"^SE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD