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HomeMy WebLinkAboutApplication and WC of TOWN OF YARMOUTH BOAl2P-0FUEA T C " 1201$ �_ s APPLICATION FOR LICENSE/PERMIT 1 t3 ' * Please complete form and attach all necessary documents1ce , !EPT. �� NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY OVEMBER 156. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: (3e cW4 CA+ T-41 VI. TAX ID: LOCATION ADDRESS: 157 8t N. �p,+CjN ,�h(ili Mk 021075 TEL.#: 5"O/ Rif() 6d$S MAILING ADDRESS: R0. 60)(3'1 R d 1-FtixmiwSi /4 Oakoi E-MAIL ADDRESS: flanc4frojohnSDA fbaok•1061 OWNER NAME: V/tck UrmcUili. 5exiL5 LL-C CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: tkvil, £)L& TEL.#:(501r) 2 O iNN g MAILING ADDRESS: 151 6(.crsf Ave,. kitt,, `(a,t flt, /114 aztv 73 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. A 011 e< 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 1. AV©M. 2. 3. 4. 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. You must provide new co ies and maintain a file at your establishment. 1. /dda- VA 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. A/)4 2. 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)(3)(a). 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. 4/1A 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. /V/A 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY 0001--/S—,574?---0 y LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 _- i LSWIMMING POOL$110ea LODGE $55 3 =TRAILER PARK $105 WHIRLPOOL $110ea. 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 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# _<50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 _FROZEN DESSERT $40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 5 5. 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 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 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 AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: C a'11 \IV' SIGNATURE: PRINT NAME&TITLE: Rev. 10/23/18 a The Commonwealth of Massachusetts Department of Industrial Accidents 111- Y §—. Office of Investigations ,, =_�;�-w 1 Congress Street, Suite 100 Boston,MA 02114-2017. :P..--_�+ www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: �eO%O\ 6' 11x1 Address: 157 6t.rni Ave City/State/Zip: W.6+ \aii o��, l"4 b13 Phone #: v cleyt A 0® 1 Oq t Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5• 0 Retail or part-time).* 6. 0 Restaurant/Bar/Eating Establishment 2.0 I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto, etc.) employees working for me in any capacity. [No workers'comp. insurance required] 8. 0 Non-profit 3.01 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]** 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, c with no employees. [No workers' comp. insurance req.] 12.N Other 1- *Any applicant that checks 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 workers'compensation policy is required and such an organization should check box#1. I am an employer that is providingrkers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: A// Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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-fines-- 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 certify under •pains a4 .„ '-� . perju that the information provided above is true and correct. � `" 0110\�`� Signature: Date: Phone#: 9<( 2Vo b0, 5 Official use only. Do not write in 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/dia s41C � u�►r�{aa�ronrvvrv� O EVIDENCE OF PROPERTY INSURANCE 12/3/2018 THIS EVIDENCE OF PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING:INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. AGENCY yvc.140.Ext{: MS)77S 3131 COMPANY The Fair Insurance Agency Inc.. Lloyds of London 619 Main Street Suite 1 Centerville MA 02632 IAIC,Nol.lsos»sn-zs7x ADDRESS:Cj AGENCY. - —1 C�U3TflMERiDlt_ OOOOZ468 SUB CODE INSURED LOAN NUMBER [POLICY NUMBER Nancy Johnson, OSA: NANCY JOHNSON ETAL I XSZ120984 PO Box 342 EFFECTIVE DATE EXPIRATION DATE 1 COAfiMtUEt7 UNTIL 11/5/2018 11/5/2019 I TERMINATEDIFCHECKED Hyannis MA 02 601 THIS REPLACES PRIOR EVIDENCE DATED: PROPERTY INFORMATION LOCATlON/DESCRIPTitb t Loc# 00015 157 Berry Avenue W Yarmouth, MA 02673 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 EVIDENCE OF PROPERTY INSURANCE 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. COVERAGE INFORMATION COVERAGE!PERILS!FRMS 'OAMOUNT OF INSURANCE I DEDUCTIBLE Building, Replacement Cost, special 400,0001 Business Income Waiting Period I 75,000 I 1 } I I ` REMARKS(Including Special Conditions) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST MORTGAGEE ADDITIONAL INSURED Town of Yarmouth 1 LOSS PAYEE Yarmouth, MA 02664 LOAN# } AUTHORIZED REPRESENTATIVE Kathy Silvia/FAIKS1 ' ACORD 27(2009112) ©1993-2009 ACORD CORPORATION. Alf INS02?(2009'12)02 rights reserved. The ACORD name and logo are registered marks of ACORD