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Home My WebLink AboutApplication and WC 4-a TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 r *Please ete form and attachQall documents .- 1 NOTE. FailureLL W��will Qt the return rn application TREUltPac' 'ti 'T : 1 21t1So Voir ESTABLISHMENT NAME: • `i �.It CO jr 'I _, • . . - . ID• • . . LOCATION ADDRESS:Z" 2 30 O d70CU,i 014,4. fog , s 0 1ygrizoie , TEL#: 0. = ' . - .h- MAILING ADDRESS: R•? -o(d roc, to-- , cu4i�.mi auk o rt1 a- •2. .4 E-MAIL ADDRESS; . •d re h r �. ° d •il pv. Cam OWNER NAME: ► ° t ' 46 4 of CORPORATION NAME I APPLICABLE): L L. Cori) MANAGER'S NAME: i4l_ �. TEL.#: L'L'$:roll 0 MAILING ADDRESS: r, f t •a c•2 ' ' CU•ei' - C . • 0 Z POOL CERTIFICATIONS: rri c) The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated El CD Pool Operators)and attach a copy of the certification to this form. -4 1. 2 m Pool operators must list a minimum of two employees currently certified in standard First Aid and Community H Cardiopulmonary Resuscitation(CPR),having one certified employee on mases at all times. Please list the employees below and attach copies of their certifications to thiThe Health Department will not use past years'records. You must provide new copies and maintain a file at your place of business. i. 2. i..<,.# +1 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: n, 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. *464.4.1 i You must provide new copies and maintain a file at your establishment. , M 1. 2. 7` PERSON IN CHARGE: G Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. VI 'L 1. 2. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-lime employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. You must i p provide new copies and maintain a file at your establishment 1. "1 2. \ IIEIlVII.ICH CERTIFICATIONS: T All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich I — Maneuver on the premises at all times. Please list your ,u,• • trained in anti-clinking�below and i C�i V1 attach copies of employee certifications to this form. The : .: Department will not use past years'records. I -.] . You must provide new copies and maintain a file at your place of business. -F 1. 3. 2. JL :c RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGINGLICEME REQUIRED FEE PERMIT 8 LICENSE REQUIRED FEE PERMIT 0 LICENSE REQUIRED FEE PERMIT S —� $55 GBCAM $55 _MOTET olio =LODGE $55 —TRAILER PARK $105 _WHIRLPOOL $SWIMMING POOL 110ea FOOD SERVICE: LICENSE0-100 REQUIREDTS FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE FEE PERMITS -->I00 SEATS s125$200 _CONTINENTALOMMN VTC. $$600 —lWHO ESALLEE s$80► —RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT N LICENSE REQUIRED FEE PERMIT Si <5500 sq. sq.8 5130 >25,000 R $285 VENDING-FOOD$25 lc =FROZEN DESSERT$40 'TOBACCO $110 /I'-O 17 NAME CHANGE: $ts AMOUNT DUE = S Zt.O.OQ *****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 permitto operate a business i£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 prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes ofthe limitations of Motel or Hotel use,Transient occupancy shall be limited to the temporary and short team 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 640,as amended,shall generally be considered Transient POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed forthe seasowmust be' by the Health Department prior to opening. Contact the Health Department to schedule the inspection throe(3)days to opening. 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 pieudomonns,total coliform and standard plate count by a State certified lab,and submitted to the Health Department three(3)days prior to opening,and query thereafter. POOL CLOSING:Every outdoor in ground swimming pool mast be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service estsblishments must be inspected by the Health Department prior to epi. 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 th must notify the Yarmouth Health Departmentthe twilledTemporary 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.yarmooth.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 results submitted to the HealthFailure to do so will result in the suspension or revocation of your Froman Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waitedwaimess service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,prepaunsion,or display of any food product by a retail or food service establishment is primed. 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 nm annually from January 1 to December31.IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATIONS)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT.QRENOVATIONS MAY REQUIRE A Slit PLAN. • DATE: (I �1 -cr SIGNATURE: BU/S r Q PRINT NAME&TITLE: 01k)?1 1 C t9 HAD IC 1S11/ D A : Rev.1012311$ The Commonwealth of Massachusetts _. � Departmettfof Industrial Accidents i. .=-.-.--...rpit= , Office oflnvestigations T.....,.:'r' — " I Congress Street,Suite 100 `'� Boston,MA 02114-2017. -, www.mass.gov/dia Workers'Compensation haurance Affidavit: General Businesses ,Apolicantinformation Please Print Legibly Business/Organization Name:_ eLch l Dig 1 VTQc to i(c C 14-e-u Address: a- C f d fou, J{ct&c:.. Ai , City/State/Zip:gatilL yc raga 1 , )1/4- 6 OPhone#: 6-0 ,3qer-; 3 Are you an employer?Check thappropriate box: ' Bus Type(required): ` 1.❑ I am a employer withfec employees(MI and/ 5. U Retail or parttime).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnershipuand have no 7. ❑Office and/or Sales(incl real estate,auto,etc.) employees working for me in any capacity. 8. 13 Non-profit [No workers'comp.insurance required] 3.❑ We area corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing no employees.[No workers'comp.insurance required]** 4.❑ We are a non-profit organization,staffed by volunteers, 11•Q Health Care with no employees.[No workers'comp.insurance req.] 12.(]Other *Any implicit that chedrs,box#1 mast also fill out the section below showing their waken'compensation policy information. **If the commute officers balm o tela emsehns,but the convocation has other employees,a weathers'compron policy is squired and such an organization,should check box#1.:,, lam an employer that is provklIng workers' Irasmenc afor my employees. IsdieFolk),in ,, , Insurance Company Name: first 0,40 CCA---f i • 5wnn 17.04rwarde A 0. 0/ 1- Insurer's Address: 6t f? r'Y1s=m S�'a e i City/State/Zip: gLIC2L r 7 1 r F - O-2R Policy#or Self-ins.Lie.# Q 00 0 SO*2 Q 16/l a Expiration Date: b 1 / 0 / fatal? 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 of up to$250.00 aday.againstthe violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cer�fy,sinter the pairs and penalties ofpe cry that theixfo:motion provided above Is and corrext • n4-14 9 4 Phone#: J- ,e,cerc( t o3 Official use only. Do not write In this area,to be completed by city or town officiat City or Town: Permit/License ense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www mass.goWdia ACCORIPICM CERTIFICATE OF LIABILITY INSURANCE DATE(1 ' 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 comocr G.H.Dunn Insurance Agency awn Deborah Hathaway No�x (508)322-3242 I No (508)322-3243 P.O.Box 330 ta Buzzards Bay,MA 02532 ACID deborah@ghdunn.com rrisunER[a)AFFORDING COVERAGE NAC N mum A, MA RETAILERS U00000 INSURED Yashraj Corp dba Town House NewsParesh Patel INSURER B: 182d Old Town House Rd South Yarmouth,MA 02664 INSURER C: INSURER D: INSURER : _INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THS IS TO CERTIFY THAT THE POLICIES OF I SIRANCE USTED BELOW HAVE BEEN ISSUED TO ThE INSURED NAMED PBOVE FOR THE POLICY PERIOD INDICATED. NDTWTTHSTPNDINN3 ANY REQUIREMENT,TERM OR COMMON OF ANY CONTRACT CR OTHER DOCUMENT WITH RESPECT TO WHICH THS ctHI IFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY 11-E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SI-OWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NOR AWL SIM POUCY POUCY LTR TYPE OF INSURANCE IwVc POUCYNMER 11/IBILVYYTIn MMAINYTYWi MTh COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea acarrmoe) $ _. MED EXP(Any ane wan) $ PERSONAL&ADV KURT _ $ GENL AGGREGATE Lon'APPLES PER: GENERAL AGGREGATE $ _ _ POLICY FlJJECT n LOC PRODUCTS-COMP/DP AIM $ OTHER: $ AUTOM09LE UABMIWY COMBINED SINGLE Leder $ (Es acadent) ANY AUTO BODILY INJURY(Pe'peon) $ OWNED SCHEDULED BODILY INJURY(PQ accident) $ AUTOS AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY AUTOS ONLY AUTOS ONLY (P dent) E $ MORELIA UAC OCCUR EACH OCCURRENCE _ $ EXCESS UPS CLANS-MADE AGGREGATE E CEO RETENTIONS $ AWORMERS CONNENSABON MB am, 014000502216118 YASHRAJ 01/01/2018 01/01/2019 STATUTE I I ERµ ANY MID PROPRIEIORPMINERIEXECUliVE Y!N Of MBAIER EXCLUDED? N/A E.L EACFIACCIDENT $ 500,000 (Mandatory in NH) EL DSMI DISEASE $ 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY UNIT s 500,000 DESCRIPTION OP OPERATIONS/LOCATIONS!VENCLE5(ACORD 101,Additional Ru wIeatluduin may ba attached*mom'panels mOSed) CERTIFICATE HOLDER CANCELLATION SHOIJI.D ANY OF TIE ABOVE DESCRIBED POLICES BE CANCELLED BORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N Town of Yarmouth Building Department ACCORDANCEWITHTIE POLICY PROVISIONS. 1146 Rt 28 South Yarmouth,MA 02664 AUTH00215)REPRESENTATIVE ®1988-2016/CORD CORPORATION. All rights reserved. /CORD 26(2016/03) The ACORD name and logo are registered marks of ACORD