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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH *-11s)) APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WITHLIQUORLICENSES MUST RETURN FORMS BY NOVEMBER I5. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: C 0 a+0 Yr y,r,0�4 h TAX ID .^, 54/V 506 LOCATION ADDRESS: /1 OL4r_ 2 2 4 Yct,rrnooi h �A TEL.#: 508-71 I'.�(,L, 1 MAILING ADDRESS:/P3 £ou 2V I Wes f YarmoL4 S H A 02407 3 E-MAIL ADDRESS: im d t tjcu-nls CaLir,a4jc.A.-Anov4h.mint OWNER NAME: CORPORATION NAME OF APPLICABLE): MANAGER'S NAME: rn i Cil 0.i..1 64((�.j'a -i S TEL.#: 50 8-Ti 1.31.6 L c c#G3 2 MAILING ADDRESS:10 Gn 1d.rrlYcid (.Corp Ccrrier+.I'11.4.. 1--i A 02 G.32 SOLI-Z(o 9 - (-loci O 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. :I11( TOrrt -S 2. /1'l,rk')q..c-1 EdWc '- S Fi Pool operators must list a minimum of two employees currently certified in standard First Aid and Community D — [li Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the r 6:2.) employees below and attach copies of their certifications to this form.The Health Department will not use past =0) [R years records. You must provide new copies and maintain a file at your place of business. f--., Q 1.SC--e—a +a c .t•q (►S+' 2 j mp Ej 3. 4. 1-1 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. You must provide new copies and maintain a file at your establishment. pp 1. 2. r PERSON IN CHARGE: , Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 'LL; 1. 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 o provide new copies and maintain a file at your establishment. n '11 se v 1. 2. �c a HEIMLICH CERTIFICATIONS: 0 g a All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich 0 Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and 41 -o r, attach copies of employee certifications to this form. The Health Department will not use past years'records. '0--0 I t You must provide new copies and maintain a file at your place of business. t I Zj) 1. ciN..) 1 t i 2. tt 4. TZiO N 3. 0 RESTAURANT SEATING: TOTAL# N J t c 0 OFFICE USE ONLY Oa N L L LODGING: -t- 4 LICENSE REQUIRE) FEE PERMIT it LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P T.#g B&B $55 CABIN $55 I MOTEL $110 ()ZZ INN $55 —CAMP $55 3 SWIMMING POOL SI 10ea-1{�t —0 -.),0 35,0 39q o1/410 LODGE $55 TRAILER PARK $105 1 WHIRLPOOL $110ea.$ e FOOD SERVICE: LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT if 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 • RETAIL SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 N.R. $50 >25,000 sq ft. $285 VENDING-FOOD $25 _<25,000 sq.ft. $150 :_—_FROZEN DESSERT$40 =TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ C.60.OO 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 I • 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 I 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.640 or 830 CMR MG,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 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 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 Y ' -'i' A 7..X DATE: i I/]7 '/k SIGNA • PRINT NAME&TITLE: lit i r h Ed t*ta rd S, ma,,r- Rev.1023/18 1F Cd Florio, Mary Alice From: Michael Edwards <medwards@coveatyarmouth.com> Sent: Tuesday, November 27, 2018 9:32 AM To: Florio, Mary Alice Subject: RE: 2019 License Renewals Hi Mary Alice, I just wanted to reconfirm our tax ID#- Yours in Hospitality, Michael J. Edwards, RRP General Manager The Cove at Yarmouth 1183 Main Street I West Yarmouth MA 02673 www.coveatyarmouth.com 1508-771-3666 x632 1800-648-3666 From: Florio, Mary Alice<MFlorio@yarmouth.ma.us> Sent:Wednesday, November 7,2018 12:09 PM To: Michael Edwards<medwards@coveatyarmouth.com> Subject: 2019 License Renewals Good Afternoon. _ Please find attached the 2019 License Renewal Application and Workers Compensation Insurance Affidavit for your business. Please complete the forms fully, and return them, along with any required certification copies,to the Health Department by December 15, 2018. If you have any problems or questions regarding the above, please let me know. Thank you. MaryAlice Florio Principle Office Assistant Yarmouth Health Division 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 1 DATE(MM/DD/YYYY) ACORD® CERTIFICATE OF LIABILITY INSURANCE /tkii....,/' 04/03/2018 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 CONTACT Diane Carmain NAME: The Armstrong Company Insurance Consultants (A/CONE Ext): (310)530-0099 (qlc,No): (310)530-0098 2780 Skypark Dr,Ste 440 E-MAIL ADDRESS: dcarmain armstrong Insco.com INSURER(S)AFFORDING COVERAGE NAIC# Torrance CA 90505 INSURER A: Ohio Casualty Insurance Co 24074 INSURED INSURER B: National Surety Corporation 21881 Cove at Yarmouth Resort Hotel Owners Association, INSURER c: Westchester Surplus Lines 10172 183 Main Street INSURER D: INSURER E West Yarmouth MA 02673-4653 INSURER F: COVERAGES CERTIFICATE NUMBER: 18/19 Liability&Prop 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 EFF POLICY EXP LTR INSD WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A BLO57691471 04/01/2018 04/01/2019 PERSONAL a ADV INJURY_ $ 1,000,000 – GE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- X LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY JECT OTHER: Employee Benefits $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) — X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED BAO57710689 04/01/2018 04/01/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident) X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 25,000,000 - B EXCESS LIAB CLAIMS MADE S0000048925986-50063 04/01/2018 04/01/2019 AGGREGATE $ 25,000,000 DED RETENTION$ $ WORKERS COMPENSATION X YN PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER A ANY PROPRIETORIPARTNER/EXECUTIVE NN/A XWO57710689 04/01/2018 04/01/2019 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Primary Limit $10,000,000 Property-Special Form C Including Named Storm D37406107 04/01/2018 04/01/2019 Deductible $5,000 Named Storm Deductible 1% DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Certificate Holder is hereby named Additional Insured with respects to the property and general liability located at:183 Main Street,Route 28,West Yarmouth,MA 02673-4653 but only as their interest may appear. *10 day Notice of Cancellation for non-payment of premium. CERTIFICATE HOLDER CANCELLATION 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. Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ,6„ ' �- ©1988-2015 ACORD CORPORATION. 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