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HomeMy WebLinkAboutApplication and WC , ', TOWN OF YARMOUTH BOARD OF HEALTH c r'' APPLICATION FOR LICENSE/PERMIT-2019 *Please complete form and attach all necessary documents by December 15 2018. NOTE:ALL BUSINESSES WIT IILIQUOR LICENSES MUST RETURN FORMS BYNOVEMBER IA Failure to do so will result in the return of your application packet ESTABLISHMENT NAME: •su4.rcoMber an 41ne Ocean TAX ID: LOCATION ADDRESS: 10-+ S• S 1Ac' D-• 5- `f a r rto,a.-4ti MA• TEL.#: 50?, 5Q 8 4 a a8 MAILING ADDRESS: "< <k V, 'k i k 1.t E-MAIL ADDRESS: Ju sA-oL.d €. hok-cytaz.L. •co M OWNER NAME: Keg ry s NJ 6.01,0 CORPORATION NAME(IF APPLICABLE): S c..,,kc 0 Mb u- m".c . MANAGER'S NAME: -3-usa •• x-1\-d o‘.d TEL.#: 5043 39'4 8 4 30 MAILING ADDRESS: c 01- s. 51tio, - Or• S• y d(Mo MA- Oar 6 K 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. Sks\-�n -.- c�a v• \� n • 2. i D M Pool operators must list a minimum of two employees currently certified in standard First Aid and Community ED 2 ...4 o Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the I m employees below and attach copies of their certifications to this form.The Health Department will not use past mc ElQ years'records. You must provide new copies and maintain a file at your place of business. 1. 7145a.Nn yVa\aSl 2. g70 ba�-a Muir-A 3. Mel.ssa Z,-41,A,,,,,, 4. R c'urt, FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food FF` .' 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. B 1. Irl ilk 2. m f' , PERSON IN CHARGE: + Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1. N p 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(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. Ni Q 2. HEIMLICH CERIINCATIONS: 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. NlR 2. 3. 4, RESTAURANT SEATING: TOTAL# 661A- 40-4 088S-03 OFFICE USE ONLY LICENREQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P # B&B $55 CABIN $55 I MOTEL $110 Q INN $55 ISW1MMINGPOOL$110ea.4 r)e(p =LODGE $55 � --TRAILER PARK $105 WHIRLPOOL $110ea FOOD SERVICE: LICENSE REEAQTUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED ham. PERMIT S 1100 SEATS $125S 2 __CONTINENTAL MM�ON VIC. $35 -- NON-PROFIT =RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED rI PERMIT S <50 ..R $50 >25,000 sq ft. $285 VENDING-FOOD$25 <25,i i i sq.R $150 FROZEN DESSERT$40 --TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 220.00 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.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 pseudomonas,total coliform and standard plate count by a State certified lab,and submitted to the Health Department three(3) 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 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 waiteriwaitress 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 REQI'A SITE . DATE: Dec. 10 o`Zo i 8 SIGNATURE: 141 MEy9 PRINT NAME TITLE: • ,ws\ ^ �.NscAck G• M Rev.1023/18 ,,�.....N SURFINC-02 DKULICK ACORU° DATE(PAWDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 11/29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOITION 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 License#1780862 MCI HUB International New England 300 Ballardvale Street NE�cOp,N�Lo,Ext):(978)657-5100 I ,No):(978)988-0038 Wilmington,MA 01887 ADDREss: INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:Granite State Insurance Company 23809 INSURED INSURER B:Safety Indemnity Insurance Company 33618 Surfcomber Inc INSURER C:National Union Fire Insurance Company of Pittsburgh,PA 19445 107 South Shore Dr INSURER D:AIM,Inc. South Yarmouth,MA 02664 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 ADD'SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD $WD IMMIDD/YYYY) IMM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE . $ 1,000,000 CLAIMS-MADE X OCCUR 02LX00899487313 09/10/2018 09/10/2019 DAMAGE TO RENTED 300,000 PREMISES(Ea occurrence) $ _ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Tef LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY (EaMaccidentMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO 3952655 09/08/2018 09/08/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSRE� ONLY X AUUTOSyyN p BODILYRINJURYTyp (Per accident) $ _ X AUTOS ONLY X AUTO ONLY (Peri accident)AMAGE $ — $ C X UMBRELLA LIAR X OCCUR EACH OCCURRENCE _ $ 10,000,000 EXCESS LIAB CLAIMS-MADE 29UD0158466399 09/10/2018 09/10/2019 AGGREGATE $ 10,000,000 DED X RETENTION$ 10,000 -$ D WORKERS PER EH MOYES'UABIUTY STATUTE T ANY PROPRgOERR/PARTNER/EXECUTIVE Y/N WCC50050175602018A 07/01/2018 07/01/2019 500,000 FIn NH)EXCLUDED? N I A • E.L.EACH ACCIDENT $ ICER/ryEIET500,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Property Policy: Lexington Ins Co #02LX00899487313-Eff 9/10/18-19;Replacement Cost Bldg 1 -107 South Shore Dr.,South Yarmouth,MA(Office Bldg) Bldg Limit$1,084,982,Ded$2,500 Bldg 2-107 South Shore Dr.,South Yarmouth,MA(Penthouses) SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Surfcomber EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Inc South Shore Dr. ACCORDANCE WITH THE POLICY PROVISIONS. 107South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE I 9'9?-1-*"• ---. ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD