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Home My WebLink AboutApplication and WC *-ot • TOWN OF YARMOUTH BOARD OF HEALTH ' Llitt APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attachQall -,sSoyy documents I.-_ ,�_-.i , . NOTE:�BUT to do so WrHLJQLJORin theLI NSIS of application� '1 v,,, ", r r,I ER 1S'. LOCATION ADDRESS:ESTABLISHMENT NAME: {-4> c f 1.6 Ai C :3rEL.TAX #,5d k75'7 7/7/ y7/ �f•,2-.k NJ -7 MAILING ADDRESS: S7' 4Py'/Ll// 7i`. a jj i r71., M•!1- 6_,1,.._46e,/ E-MAIL ADDRESS: lP G' 2 Ka /re-a.S Y)e. OWNER NAME: Do u ar CORPORATION NAME(IF APPLICABLE): �T-0 K , !_C. C MANAGER'S NAME:�ie r t)t. tri- — TEL.#: 7 7V-•?(a? 7 MAILING ADDRESS: 7 Z.46(b) //I, 5, ya r'A4 if x!71, M d,1/�/ 4z POOL CERTIFICATIONS: ' The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s)and attach a copy of the certificati.. to this form. T �7 1. 2. D = Writ r—, Pool operators must list a minimum o . employees currently certifi standard First Aid and Community -- tV til Cardiopulmonary Resuscitation(C' ' ,having one certified employ on premises at all times. Please list the _ 0) employees below and attach cop' of their certifications to this fo The Health Department will not use past IC years records. You must p .e new copies and main file at your place of business. :--1 cr, L) 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one fills-time employee who is certified as a Food 7,1 Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. ``3 Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. /y ier b 1.4.ar-le___. 2. W PERSON IN CHARGE: , Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. J ler 2)1-!CU'" — 2. 0r /a RR1.-r1n, 4 ALLERGEN CERTIFICATIONS: 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(GX3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. ,. .--7/P r -0 u6 r- - 2. klpJ (e.t_ �)hgri-cein 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 i1-- trained in anti-choking procedures below and attach copies of employee certifications to this form. The ealth D rtment will not use past years'records. You must provide new copies and maintain a file at your place oaf business.b 1. ��iP Y' iL c f" 2. •�C(1-.(i let fC abet-1-56/1 3. •-(1A1^tt__ Q. &r c, 4. .ia RESTAURANT SEATING: TOTAL# 37 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —INNB&Bs CABIN $55 MOTEL $110 --LODGE5 CAMP $55 _SWIMMING POOL$110ea. E --TRAILER PARK $105 WHIRLPOOL S110ea. FOOD SERVICE: LICENSE REQIERED FEE PERMIT# LICENSE REQUIRED F3EE PERMIT# LICENSE REQUIRED FEE PERMIT# 1>I00 SEATS $200 CONTINENTAL $60 ---,WHOLESALE $30COMMON VIC. RETAIL SERVICE: RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# X50 it. $50 >25,000 .R. $285 VENDING-FOOD $25 _,QS.i 1 sq.$. $150 PRbZEN T$40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ IB5.Qp *****P$,E4$E 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 °1 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 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 rior to opening.PLEASE NQTE: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 fi i = the requires Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtain=• 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. ,1, The Commonwealth of Massachusetts Department ofindustrial Accidents '. =1;r .r Office of Investigations 11\ibii,'-Er= 1 Congress SVreeI Suite 10D Boston,MAv00) estigations •....l. www.mass gov/ala Workers' Compensation Insurance Affidavit: General Businesses ,A,nnlicant Information Please Print Leuibly Business/Organization Name: ii- N.-- ,,4 ki .4 — 7Th L...- Address: '7/ / t a/ 4..._ :*". City/State/Zip: O. icon i3Oy?'1 i ,, �l n- Phone#: 5-or- 7 76-- 7 7 7/ Are you an employer?C k the appropriate box: Business Type(required): 1.❑ I am a employer with anployees(full and/ 5. ❑Retail or part-time).* 6. 'I estaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 10.(]Manufacturing no employees.[No workers'comp.insurance required]*' 11Health Care 4.❑ We are a non-profit organization,staffed by volunteers, 1:-.2„ with no employees. [No workers'comp..insurance req.] 12. Other 'Any applicant that(*edcs box#1 must also fill out the section below showing their workers'compensation policy information. "If the corporate officers have exempted themselves,but the corporation has other employees,a warless'compensation policy is wed and such en cion should check box#1. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy information. Insurance Company Name: j P t _Y'F-coiz( - nl 5 i Co • Insurer's Address: City/State/Zip: Policy#or Self-ins.Lia# V V " LCCi) 6,a / Expiration Date: 6/z 7// 2 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 MOL 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 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifr,under the pairs and penalties of perjury that the information provided above is true and cornea. Signature: LQtl la..- Z',f. Q(.rti' Date: 1/43/a-5-1/9 Phone#: cif 39f-7Y Official use only. Do not write hi this area,to be completed by city or town official City or Town: Permit/License# 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.gov/iia • AC CERTIFICATE OF LIABILITY INSURANCE DATE (M"DONYTY) 03/25/2019 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 POUCIES 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 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 CONTACTSharon Covina PHONE McShea Insurance Agency,Inc , . (508)420.9011 ,Not(508)420-9010 1645 Falmouth Road,Rt 28 BLDG DADDRESS: sharon@mcsheainsurance.com Centerville,MA 02632 INSURER(S)AFFORDING COVERAGE NAIC S INSURER A: The Hartford Insurance Company 22357 INSURED INSURER B: Ann&Fran's Kitchen DBA TTDK,LLC INSURER C: 38 Stoney Hill Dr INSURER°' South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 1 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 AWL SUBR POUCY EFF POLICY EXP LTR TYPE OF INSURANCE MSD VVI) POUCY NUMBER (MWDD/YYYYI (MMIDOIYYYY) LIMITS 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 APPUES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC PRODUCTS-COMP/OP AGO $ OTHER: $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _AUTOS ONLY (Per accident) _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ A WORKERS COMPENSATION 08WECCQ6219 06/27/2018 06/27/2019 X SINZUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NE.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? Nn El./A(Mandatory In In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRIPTTIION OFOFOPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POUCY PROVISIONS. AUTO//PRESENTATIVE I �7 (SSC) 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016!03) The ACORD name and logo are registered marks of ACORD Printed by SSC on March 25,2019 at 10:09AM