Loading...
HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2019 _ *Please completeform and attach all necessary documents by I« 15 2018. NOTE:ALL BUSNS WTTHL[QUORL1CNS SMUSTRETURN '1" l ;Y of RIS'. Failure to do so will result m the return of your application packet. ESTABLISHMENT NAME: 3'c,—c A t Lr,4-taT_s•rot-, 'KL -lC TAX ID: LOCATION ADDRESS: 7.1-ci TZ.l c 6 A TEL.#: SZJO y MAILING ADDRESS: SA ac, y f 4 d fp rete ,w r .tom r3Z1 Z P E-MAIL ADDRESS: jtac..8A5- ckSleep bat. ,( Jfi OWNER NAME: Sa i4e, CORPORATION NAME(IF APPLICABLE): J -r cc *-t/C._ MANAGER'S NAME: C.Iir-.-s . L)e4 r4, TEL.#: SZ 7 / MAILING ADDRESS: ;: 27r POOL CER I ATIONS: m The pool rviaor must be certified as a Pool Operator,as required by State law. Please list the designated .0 [� Pool 0 : 'r(s)and attach a copy of the certification to this form. w () 2. 2 Pool operators must list a minimum of two employees currently certified in standard First Aid and Community o Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the ri 0 employees below and attach copies of their 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. 3. 4. ; FOOD PROTECTION MANAGERS-CERTIFICATIONS: e 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. I PIease 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 VL/C44cJ4?C e 2. PERSON IN CHARGE: -V ` Each food establishment must have at least one Person In Charge(PIC)on site during/hours of operation. 1. �C.k r 4 / SA)0,u I 2. L J�4 r�P l�G 1I 7j 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. 1. 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 HeaUk Department will not use past years'records. You must provide new copies and maintain a file at your place of business. 1. \c.NLef r 2. Rada_ 4,S-00,0 r 3. c^_►.,e. e 4. 7i ICr.c� t, RESTAURANT SEATING: TOTAL# Bd klF l5-6 o2,4 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 —INN $55 CAMP $55 =SWIMMING POOL$l l0ea =LODGE $55 TRAILER PARK $105 WHIRLPOOL $110es. FOOD SERVICE: LICENSE ,QUFEE # LICENSE REQUIRED FEE PERMIT# LICENSE UIRED FEE PERMIT# j 0-100 A SEATS $125 P�0 7 _CONTINENTAL $35 NON-PROFIT $30 _>I00 SEATS $200 COMMON VIC. $60 ;I QIj•Z WHOLESALE $80 RETAIL SERVICE: _RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ,50 sq.ft. $50 >25,000 ft $285 VENDING-FOOD$25 <25,000sq.IL $150II–FROZEN ESSERT$40 TOBACCO SI10 NAME CHANGE: $15 AMOUNT DUE = S 185.Ob 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 �XP 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 t/. NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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 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 poeudomopas,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 opining. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department • 1'i < the required Temporary Food Service Application form 72 hours prior to the catered event These forms can beat the Health Department,or from the Town's website at wwwyannouth.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. 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 RE i,4 1 A SITE 'LA DATE: (t 47 v�/S3 SIGNATURE: I 4, PRINT NAME& 11 iLE: r1 cotep A < <-•A-CL(S (J ) Rev.10/2.3/18 From:Donna FaxID: Page 1 of 2 Date:11/292018 01:27 PM Page:1 of 2 Phone: (5rden& Sullk?an Fax: (5 ) 790-1414 Insurance Agencies Fax From: Donna To: Licensing/Health Dept Pages: 2 Fax: (508) 760-3472 Date: 11/29/2018 01 :25:33 PM Phone: ( ) - Subject: Message: RECEIVE. Noy 9 2018 HEALTH DEPT From:Donna FaxID: Page 2 of 2 Date:1 1/29/201 8 01:27 PM Page:2 of 2 ____..........N JAMES-2 OP ID:.DS ACORO DATE(MM10'D/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/29!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 Fii2AaNiEACT Bryden 8 Sullivan Insurance Bryden&Sullivan Ins Agency PHONE o,Ext):508-775-6060 Fax 508-790-1414 88 Falmouth Road (Arc,No): Hyannis, MA 02601 EMAIL Bryden&Sullivan Insurance aDOREss: INSURER(S)AFFORDING COVERAGE NAIC M INSURER A:The Hartford '22357 INSURED James A. Liadis, Inc. DBA INSURER B:Capitol Specialty Ins Co Black Sheep Bah&Grill 84 Rocky Ridge Road INSURER C: Dennis,MA 02638 INSURER 0: 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 ADOL',SUER' POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD MND I POLICY NUMBER SMMIDDIYYYYL(MM1DDIYYYY) '' LIMITS B X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 X CCCUR CS1700139202 02/25/2018 02/25/2019 DAMAGE TO RENTED 100,000 CLAIPAS-MADE PREMI$ES(EEoccucenCe) $ MED EXP(Any Air persor) $ 5,000 X Liquor PERSONAL€..ADA INJURY $ 1,000,000 GENL AGGREGATE LIMIT AP-'LIESPER .GENERAL AGGREGATE $ 2,000,000 POLICY PR .) LOC 2,000,000 I PRODUC'S-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY : COMBINED SINGLE LIMIT ,Ea accident). $ ANY AUTC BODILY INL IRY(Per person) $ OWNED SCHEDULED AUTOS ONLY _ AUTOS �', I BODILY IN,URY(Per accident) $ FIRED NON-CWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY 'iPe'accident I $ UMBRELLA LIAB CCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE '. 'AGGREGATE $ DEC RETENTION$ $ A WORKERS COMPENSATION PER 0TH AND EMPLOYERS'LIABILITY Y 1 N STA-LTE ER. ANY PROPRIETCRIPARTAERIEAECUTIVE 08WECCI6466 03/08/2018 03/08/2019 500,000 OFFICER/MEMBER ECLUDEDI N N 1 A +E.L.EACH ACCIDENT $ (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ 500,000 II ves desu'be under 500,000 DESCRIPTIOV OF OPERATIONS below I.E L DISEASE-POLICY LIMIT $ B Liquor Liabilit .CS1700139202 02/25/2018 02/25/2019 !Each clai 1,000,000 'Aggregate 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space's required) + RECEIVED Restaurant NOV, 'I92U18 HEALTH DEPT. CERTIFICATE HOLDER CANCELLATION YARMO03 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. YARMOUTH TOWN HALL Licensing 1146 MAIN ST AUTHORIZED REPRESENTATIVE S. YARMOUTH, MA 02664 Bryden &Sullivan Insurance 1 _ ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD