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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH L71rAPPLICATION FOR LICENSE/PERMIT-2019 `_ *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WITH LIQUOR LICENSESMUSTRETURNFORMSBYNOVEMBER 13h. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: ✓ .. • t _s e_ i' IP, 11 4 , Iv• LOCATION ADDRESS:4 0 , e : , O Lt(r<pn p, Mia L.#: (S% '39 Y-0$85 7 MAILING ADDRESS:n M'e E-MAIL ADDRESS: ri ppe,�. 1‘� ` od ct`, 0 An I • r Z.r^ OWNER NAME: CORPORATION NAME(IF APPLICABLE): DQ C (1 •-• 1✓1 MANAGER'S NAME: pcx tri eio, Wg.(c, TEL.#'`>Off `i77 21i$ MAILING ADDRESS: d 9w)t C( 7 Yo cesrA(1IK 119 11 O 26 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 certification to this form. 1. 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 T. Z `'F° employees below and attach copies of their certifications to this form.The Health Department will not use past D o 5 yearsrecords. You must provide new copies and maintain a file at your place of business. (�) I -.t = 1. 2. 0 iv C' 3. 4. m o Ga ..i co 0 FOOD PROTECTION MANAGERS-CERTIFICATIONS: 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.71 You must provide new copies and maintain a file at your establishment. 1. Ed K1, ed 1lc 2. ..�._ `d PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on 'J r siteduring hours of operation. 1. ON 42 c,. DIohItilt ply 2. +r1cra_ wt:tint., r:� 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(G)(3Xa). Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and�maaiintain a file at your establishment. 1. QuV�art) ( " 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 anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. /gT)i (.01-1.. k- 2. PO rt n0. f?e,e1 n1 o w 3. T'1 ✓1cA m*0re 4. RESTAURANT SEATING: TOTAL# 550 60 ---114 _63,�-10 .— OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT if LICENSE REQUIRED FEE PERMIT# B&B $55 —INN $55 C� $55$55 _MOTEL 5110 1,ODGE $55 =TRAILER PARK $105 =WHIRLPOOLSWIMMING �L$1110ea FOOD SERVICE: LICENSE REQUIRED FEE P$IjIT$.7� LIC OSSREEQUIRED $FEE PERMIT# LICENSE RE USD Ulf PERMIT S _l_ >100 SEATS $200 O COMMON VIC. $60 OnStitt =WHOLESALE $80 —RESIT).KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT if LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT it <50-.11. $50 >25,000 sq.11. $285 VENDING-FOOD $25 _<25,I r r sq.ft. $150LT ROZEN DESSERT$40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 185.NI 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 Al•'I+'1llAVIT 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 2( 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 in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFÉS: 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 ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO 'OVED BY THE BOARD ti - -! TH PRIOR TO COMMENCEMENT. RENOVATIONS MQ :.y.{!ji'i yr 'LAN 's DATE: , 17— '' SIGNATU1t-I :-........._tom ` . + PRINT NAME&TITLE: " •4/, "ftC t d►'(o to 'j"re,,s re I Rev.10/23/18 PICCA-1 OP ID: DS ACOREA" CERTIFICATE OF LIABILITY INSURANCE DATE(M11/133/2018/2018) 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 508-775-6060 CONTACT Bryden&Sullivan Insurance Bryden&Sullivan Ins Agency PHONE 508-775-6060 FAX 508-790-1414 88 Falmouth Road (A/C,No,Ext): (A/C,No): Hyannis,MA 02601 E-MAIL DDRESS: Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbel la Protection INSURED Cape Deli Foods,Inc.dba INSURER B:Guard Insurance Group Piccadilly Deli 1105 Main Street INSURER C: South Yarmouth,MA 02664 INSURER D 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. INTRR ADDL TYPE OF INSURANCE INSD SWVD POLICY NUMBER (UBR MM/DDY�) (MM/r)..Y�I LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 8500062959 10/01/2018 10/01/2019 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 X Liquor Liability PERSONAL BADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSEONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY AUUTOS ONLY PROPERTY accidentDAMAGE A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE 4600062960 10/01/2018 10/01/2019 AGGREGATE $ 1,000,000 DED X RETENTION$ 10000 $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITYY/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE CAWC986704 08/01/2018 08/01/2019 500,000 OFFICER/MEMBER EXCLUDED? 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 $ A Liquor Liability 8500062959 10/01/2018 10/01/2019 Per Occur 1,000,000 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Restaurant/Deli CERTIFICATE HOLDER CANCELLATION TOWN-12 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. 1146 RTE 28 S YARMOUTH,MA 02664 AUTHORIZED REPRESENTATIVE Bryden&Sullivan Insurance ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD