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Home My WebLink AboutApplication and WC LOCATION ADDRESS: 7'/2 I1k.4( S 7— (S, TEL.#: Jr`3 9<i- 5-2-s-2, MAILING ADDRESS: ,S a-vwQ-- E-MAIL ADDRESS: eo S -! 0..e-e, c.-,,,-- G lEg OMGE OWNER NAME: Pt g4-7eS CYC rpt ST ! vt_. CORPORATION NAME(IF APPLICABLE): P 1 KITS NOV 18 2018 MANAGER'S NAME: Cha L C-4-3t-Cc' TEL.#: MAILING ADDRESS: --741 211A4 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 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. 2. 3. 4 FOOD PROTECTION MANAGERS - CERIIF'1CATIONS: 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. 1. & u 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. 4wzfi Z47/-e— 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. L -- 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. 2. F50 -lchb $125 3. 4. et, Go 2e-s'c5ti s 50 ' RESTAURANT SEATING: TOTAL# ao p-g $ LODGING: OFFICE USE ONLY ts2%1 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B—INN $55 -55 C� $55 55 —SWIMMING $110 LODGE $55 TRAILER PARK $105 POOOIPOOL$$11� FOOD SERVICE: T TCPIJCT;DICT TIO FTI VVV DDD➢NTT Ji T I V.TQL nun'Tin rr. rrr 111,1%1 ITT 41 T r/rT11T"-,TT/NT TTT%Tr T.T.T T.TTs.sr.T... CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED 1/- Town 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. MG 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 rnr% f iI %A AM%T/YTT1 KT`1TT TT'3.1f U 7 A TT/NATO 111 A V T1 !1T TTT)L A QTTe TIT A 10 Florio, Mary Alice From: Florio, Mary Alice Sent: Wednesday, November 28, 2018 1:08 PM To: Marketplace at Pirate's Cove (cove5@aol.com) Subject: Health Dept. License Fees Good afternoon. We just received your application for the Marketplace at Pirate's Cove, but there was no check enclosed for payment of the fees. Would you please send the payment totaling$275.00(Food Service-$125; Common Vic.-$60; Retail Food -$50; Frozen Dessert-$40) at your earliest convenience? Thank you. MaryAlice Florio Principle Office Assistant Yarmouth Health Division 1146 Route 28 South Yarmouth, MA 02664 508-398-2231,ext. 1241 21E@ OLS WEED Ott 03 ?O111 HEALTH DEPT. ' GA- f cutti - , - .,* ,,,,,p,4? P, cat .. SZk The Commonwealth of Massachusetts Department of Industrial Accidents = I.: Office of Investigations T _ 1 Congress Street,Suite 100 StIar Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: MA-le-0et 4T Pt-'• 'fS CeNser. , Address: MA--t f City/State/Zip: S. `('el-4-010011+ OM—UVilLione#: 5-7)e 2— Aryolyn employer?Check the appropriate box: Business Type(required): 1. I am a em.loyer with F employees(full and/ 5• D etail art-times* 6. [ estaurantBar/Eating Establishment 2.❑ 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 10.0 Manufacturing no employees. [No workers' comp.insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other *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 providing workers'compensation insurance for my employee& Below is the policy information. Insurance Company Name: 1-jr--4-4-4.15-X.-(N 5.111. C 6 if,,o Insurer's Address: 471 L 1-"( retijiAi5`w'Yi s-r--! p o ,• 5 5 I City/State/Zip: /41/Z 0 V ), / 4 q iia (10 Policy#or Self-ins.L•ac.# ki•-•l C'. /2 3L1'1 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 fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the pains and penalties of perjury that the information provided above is true and correct. Signature: rV Date: 1/ `<'j —ZcY t$ Phone#: (.5-6 T Li'JroZ s�-- 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 PCMAN-2 OP ID: LA '`��RET CERTIFICATE OF LIABILITY INSURANCE _ X11/19/2018 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(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 989-835-6701 atfeCT Karl T. leuter leuter Insurance Group PHONE989-835-6701 I FAX 989-835-2964 414 Townsend St.P.O.Box 552 (MC,�N�o Midland,MI 48640 ADDRESS:karl@ieuter.com Karl T.leuter INSURER(S)AFFORDING COVERAGE NAIC INSURER A:T.H.E. Insurance Co INSURED Pirates Cove East INSURER B: Pirates Cove East 728&742 Main St.South 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. INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRINSD YYVD IMMIDDIYYYY) (MMIDDIYYYY) 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 APPLIES PER: GENERAL AGGREGATE $ POLICY Tel: LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY AUTOS BODILY INJURYpper accident) $ _ AUTOS ONLY Mitere P 08ERdent)AM AGE T S ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS EMPPLLCOMPENSATIONBIILYIN X PER ER H ANY PROPRIETORIPARTNER/EXECUTIVE WC0005086 01/01/2019 01/01/2020 1,000,000 A�FFFICER/MEEMSgE�R�EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000, 0 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRPTION OF OPERATIONS I LOCATIONS/VEHCLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is moulted) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WE.L BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE g1C.e ACORD 25(2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i OFY pF` 'eft TOWN CC .. l . . . LICEN ING OFFICE iol . 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1268 DUE BY DECEMBER 1, 2018 RENEWAL APPLICATION FORM FOR 2019 Business Name: MARKET PLACE AT PIRATE'S COVE Tel #: 508-394-5252 Address: 742 Main St., South Yarmouth, Ma. 02664 Box#: Email Address: Owner/Manager: Robert Love FID#: S.S.#: If Inc. must provide FID# If not Inc. must provide SS# Under Chapt. 152, Sec 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 Co. does not have a certificate of worker's compensation insurance As part of renewal or issuance you must attach a copy of your certificate if checked here: X LICENSE/PERMIT TOTAL DUE: $2,240. Automatic Amusement (28) $2,240.00 $ 80,00 per machine Class I and II car License: $ 105.00 per year Amusement License: $ 105.00 per year Bowling License: $ 55.00 Pt lane, $30.00 ea add. Transient Vendor License: $ 30.00 per year Pool Table License: $ 55.00 lst table, $30.00 ea add. Sale of Christmas Trees: $ 55.00 Misc. Permit or License: $ 35.00 SIGNATURE: LJDATE: it $1 a-r