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HomeMy WebLinkAboutApplication and WC Failure to do so will result in the return of your application packet Cap+a►(r ccyr t N-ocs.c.. ESTABLISHMENT NAME: .l C 1n1 pnfec-i)C't5 eS "--1----1J L, D 1 a Y( TAX ID: LOCATION ADDRESS:-36s D( t-i(fir► n et./S. ^r rn M/ TEL.#: SO c? - 7 -2-g i i° MAILING ADDRESS: N 0 2-(p Io Y E-MAIL ADDRESS: Cal r o I J uo a.S o N 5 7 c (3 N o .Co(A OWNER NAME: C o l W S o". .Te4 Cc rz..� V) S� CORPORATION NAME(IF APPLICABLE): ZCLJ S pp c v S 1 TA.MANAGERS NAME: Sa e M0 co cve_r- TEL.#: A 6vve..., MAILING ADDRESS: S efi-n Q 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. 0# 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 p 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: r- n a All food service establishments are required to have at least one full-time employee who is certified as a Food = c Protection Manager,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. v ,-- Please Please attach copies of certification to this application. The Health Department will not use past years'records. m ER You must provide new copies and maintain a file at your establishment. :-I 1. C-kl4Zo( WalCzYv 2. '3-Q20), U•Dcle PERSON IN CHARGE: �..1 E. n Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. t 1. 0CP-o (.134 C.AIN.- , 2. J 2- 'c l .) ALLERGEN CERTIFICATIONS: :6 All food service establishments are required to have at least one full-time employee who has Allergen certification,. i w. C, 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. Or7`o\.. l/3 43-\y-\ 2. C-o V-. • ,e-..._ 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 ,loyees trained in anti-choking procedures below and attach copies of employee certifications to this form. The :ealth Department will not use past years'records. Yon must provide new copies and maintain a file at your place of business. 1. N1 A- . 2. 3. 4. RESTAURANT SEATING: TOTAL# Z 2— (fid k.411-1(o-1(07i-O3 OFFICE USE ONLY 6O'yhc-Ito-4110 I-03 LODGING: LICENSE REQUIRED FEE PERMIT 8 LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT S B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 —SWIMMING POOL$110ea LODGE $55 1IQ�00/ —"MAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE 1 r !I LICENSE REQUIRED FEE PERMITS LICENSE UIRED FEE PERMIT S 4->00 SEATS $12563 _LCMT�c �q $ — l --Af8 =RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT if LICENSE REQUIRED FEE PERMIT II <50 sq.R $50 >25,000 sq ft $285 VENDING-FOOD $25 —<25,000 NA $150 ROZEN DESSERT $40 —TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 210.00 PLEASE TURN OVER AND COMPLETE OTHERE OF FORM 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 serve 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 . . 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 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 MAY REQUIRE A/SITE PLAN. DATE: iq t c/a SIGNATURE:�cn I�t1 7� C b PRINT NAME&TITLE:C pko v� Svy\. / 6 Rev.10123/15 The Commonwealth of Massachusetts Department of Industrial Accidents ,� —+:14i , Office oflnvestigations _ -n ., 1 Congress Street,Suite 100 Boston,M4 02114-2017. www.mass.gov/dia =1 Workers' Compensation Insurance Affidavit: General Businesses Annlic ant Information Please Print Legibly Business/Organization Name: E :mss n,se. c, 36 c C gL, s - -rn 1-o u 5-_, Address: 3c16 o td_ tic i t Si- . City/State/Zip: .� \for(V1 s-1 D, J D h net#: 5o E --7 c)0 ——29 If Are you an employer?Check the appropriate box: Business Type(required): 1.El I am a employer with 3 —k employees(full and/ 5. 0 Retail or parttime).* 6. 0 Restanrant/Bar/Eating Establishment 2.0 I 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. 0 Non-profit 3.0 We are a corporation and its officers have exercised 9. 0 Entertainment their right of exemption per c. 152,§1(4),and we have 1o.0 Manufacturing no employees.[No workers'comp.insurance required]** 11.❑Health Care 4.0 We are a non-profit organization,staffed by volunteers, a with no employees. [No workers'comp.insurance req.] 12.01Other (e4 ;"PAC�A4r *Any applicant that c1edCs box#1 must also fill out the section below showing their wormers'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 acre an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: A, . Vel . Mc Qn sore()ren t e co Insurer's Address: 5 L it fl-u2, ) ?, CJ , g 40 70 i /0-A‘ f)s-6.0.,. MIN 01.80 3 City/State/Zip: Policy#or Self-ins.Lic.# W Cr-- 5 00 }0leg 7 8 0— .O 1.8 IN Expiration Date: 5 i Li/2-0 I of 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 pains and penalties of perjury that the information provided above is true and correct. Sigma= • IS, IA) — Date: f8l/E/I? Phone#: 50 - 760—ZgIg Official use only. Do not write in this area,to be convicted by city or town g icier[ 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#: p www.massoov/dia Client#:765721 2CAPTAINFA1 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE( DDYYYY) 12/03/2018 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(les)must 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 NAMDowling&O'Neil Insurance Agy PHONE 508 775-1620 FAx 5087781218 973 lyannough Road E Ex* (AIC,N°?` ADDRESS: P.O.BOX 1990 INSURERS)AFFORDING COVERAGE IANC I Hyannis,MA 02601 wsuRER A:Northem Security Insurance Company Inc 25992 INSURED INSURER B:Associated Empkrie,s bnwranee Caapay 11104 JCW Enterprises,Inc. INSURER C: dba The Captain Farris House 308 Old Main Street INSURER D' 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. LTRLT R TYPE OF INSURANCE ADDLWVp POLICY EFF POLICY EXP MISRPOLICY NUMBER (MMtDWYyYY) LAMS A GENERALLIABIUTY BP21051050 04/20/2018 04/2012019 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ES(EaaEo«xsDence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE _$4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000 X POLICY PRO- JECT LOC `$ AUTOMOBILE IJABILlTY COMBINED SINGLE LIMIT (Ea accident) _$ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC50050187802018A 05!04/2018 05/04/2019 X VVC STATU- 2414" AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER OFFER�/rAREMBER EXCLUDED?ECUTIVE N N/A EL EACH ACCIDENT $1,000,000 (Mandatory In NH) EL DISEASE-EA EMPLOYEE $1,000,000 I yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,I more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION JCW Enterprises,Inc SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 308 Old Main Street ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE -?N✓f...- `-1e7 Cw ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S224053/M224052 RPSW1