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Home My WebLink AboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH It APPLICATION FOR LICENSE/PERMIT-2019 ' *Please co�form and attapchh all necessary documents by December 1l 2018. NOTE: FailureLLBto do so willresult inWITH retjk urn of your ST application RNpa oeB�Nbvls�r ls� ESTABLISHMENT NAME: 'la ' ... �A. . . .u, 10• , - LOCATION ADDRESS: .33c Mai SA-vt1 TEL.#:fD1r'--77I-'SI, ' MAILING ADDRESS: E-MAIL ADDRESS: h&oLt O 01.Com' OWNER NAME: iZ GU-Zgi../rn,0.e_Ltyc., ' CORPORATION NANEEJF AP .ICABLE): ..notc _S er sterpr LS C� MANAGER'S NAME:?lea 2....C.-r be 4"Q TEL#: MAILING ADDRESS: 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 years'records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS-CERTIFICATIONS: D o All food service establishments are required to have at least one full-time employee who is certified as a Food it r•:- RI 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. m u You must provide new copies and maintain a file at your establis , eat. .� o ) MP/ 1. , SCil \ ( l,— 2. a' S ---I ttiL,C.,„ PERSON IN CHARGE: 5 i Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. Odin CYN 2 • ALLERGEN CERTIFICATIONS: d All food service establishments are required to have at least one full-time employee who has Allergen certification, )d t as defined in the State Sanitary Code for Food Service Establishments,105 CMR 590.009(GX3Xa). Please attach cij copies of certification to this application. The Health Department will not use past years'records. You must `4 -L provide new copies and maintain a file at your establishment. 1. CJ(W 1^-0 t� 2. $ IIEIMLICH CERTIFICATIONS: c 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 ll attach copies of employee certifications to this form. The Health Department will not use past years'records. !v' You must provide new co ics and maintain` a file at your place of bus* ess. —7 1.1 W�1 riC_�+-- 2. J ( '.anit ,LS 3. 4. RESTAURANT SEATING: TOTAL# q-6332-r-OS OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# —INNB&B $55$55 CAMP $55 MOTEL $110 —LODGE $55 $55 _SWIMMING POOL$110e. __TRAILER PARK $105 _WHIRLPOOL S110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35G NON-PROPIT $30 >I00 SEATS $200 di"9-4(1' J_COMMON VIC. $60 :3L'Q/1•. -WHOLESALE $80 —REBID. RETAIL SERVICE: 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 <25,000 sq.8. $150 FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $2..G0-00 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 W 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 o 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 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 PRODUCE 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. ITIS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15,2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MO FEL OR P•• (i.e., PAINTING, NEW EQUIPMENT,ETC.),MUST BE REPORTED TO AND 'PR• ) BY THE : . '-'•s OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY ' .1 : -A P DATE: \\\ `\' SIGNATURE: _ PRINT NAME& ITILE: S/GYl( G lta- —Lawn \ t S Rev.10/23/18J! r ® DATE(MM/DOJYYYY CERTIFICATE OF LIABILITY INSURANCE 10/17/2018 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 pollcy(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 NAME: STANDISH INSURANCE GROUP INC. PHONE 774.283.4425 FAX 774.283.4243 303 COURT STREET UNIT 1B EE MAIL'Est): INC,No): PLYMOUTH,MA. 02360 ADDRESS: ANDYR@STANDISHINSURANCE.COM INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Lloyds Of London INSURED __. _....... _.. _... .-.INSURER B:LIBERTY MUTUAL _. .,., .... KOUNADIS ENTERPRISES CAPITOL SPECIAL INSURER C: THE YARMOUTH HOUSE INSURER D: 335 MAIN ST INSURER E WEST YARMOUTH MA 02673 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS IN$R ADDL.SUBR POLICY EFF POLICY EXP LTR, TYPE OF INSURANCE Wgp WW1WW1POLICY NUMBER JMM1017 /R IYYYY1 (MMDM'YYI LIMITS X COMMERCIAL GENERAL LIABILITY DSCPK0543 4/01/2018 4/01/2019,EACH OCCURRENCE $ 1,000,000 A DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occ Jr encs) S 100,000 MED EXP(Any one person( $ 10000 PERSONAL S ADV INJURY S 1000000 GEN_AGGREGATE.LIMIT APPLIES PER GENERAL AGGREGATE $ 20,000,000 POLICY PRO" JECT LOC PRODUCTS COMPIOP AGG $ OTHER ... ..._. S. ._ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S + (Ea accident)__. ANY AUTO BODILY INJURY(Per peraonl $ OWNED SCHEDULED BODILY INJURY Per accd,nt) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per.eccr Ieni)__,. $ S UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE f DED RETENTIONS S WORKERS COMPENSATION WC5318616095018 P€k OT" AND EMPLOYERS'LIABILITY Y/N 5/01/2018 5/01/2019 5"fATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE L EACH ACCIDENT S 500.000 B OFFICER/MEMBER EXCLUDED �� N/A (Mandatory In NH) E L DISEASE-EA EMPLOYEE$ .-.. .......500.000. If yesdescribe under DESCRIPTION OF OPERATIONS Wow E L DISEASE-POLICY LIMIT f 500A00 LIQUOR LIABILITY CS 1800192501 4/01/2018 4/01/2019 $1,000,000 PER OCCURENCE $2,000,000 GENERAL AGGREGATE DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space is raquirad) CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 RTE 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTH YARMOUTH MA 02664 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 07198 2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD