Loading...
HomeMy WebLinkAboutApplication and WC • • KM168tt ilfiltutsr s TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR -2019 . : -Scam and Mich all dommti nus mits,du :•A41 1...1 is•,'WM ill�:1 .'W r.,, �' Failure to do so wSl ,, , your application ' 111 N ESTABL.MH !'NAME: Kint115. � c: :.,.. ,� TABU). �► LOCATION ADDRESS: r TEL* ' .362.355 �••• MAILING ADDRESS: Z,rq,�pp aroj AM 02b7 C...) 15 OWNER Miff: Jolova- Ate..�y��' j.�^ern 11 CORPORATIONNAME(IF APPLICABLE) ' ,t MANAGER'S NAGER'S NAME: m len l.rt P Mann r TEL.* 3535 4e 1I , MAILING ADDRESS: t Si/5 ris+.5.i " tt. sHt+. nes 5 _ c; ` <y a.►, POOL CERTTFICATLONS: J D t .. •_supervisor Pool i e)and attache copy ec a� ,a required by Stats law,Prase listtheto dds form. *signated 2::::7,.•Y -1 : 1. muffs 4t ks 2. m IR pd,• ti cc ca m: Pool operetta must list a minimum m of,two employees acre*certified in standard First Aid and C 1► .-moi s. Please list dte \ and attach copieaofl r having etothis�T e p°alumni's at rtmall wW not=past _ �, yeas records.You must provide new eopies and nulla abs a Ms at your phtoep� Loot' 2.C ... 3. Y%It h s 4. allele e triVe6 lnr3 m > m re Q. FOOD PROTECTION MANAGERS•CERTIFICATIONS: € a 5 All hod service are required to have at least one lids-time employee who is certified as a Foodt. O 2 Pintaotion as defined in the State y Code for Food Service 105 CMR 590.000. > �C Q- C3 Please attach copies ofeestificadonmthis application.The Health Department wMn tseepaetymon'r You mustprovide new copies and maintain a Me at your establishment. ='to'a� 1. 2. li'"':''.r1 PERSON LN CHARGE: , ! Each hod eslablitinmaet Mgt have at least one Person la Chage(NC)on site daring hours of operation. 1, 2. • AILM1GENCERT'IFICATIONS: . AB hod service establisimtents are requhudtohave at=ewe lidl-timeemployee who has Mimeo aa a, as defined lathe State Sanity Code for Food Service Establishments,105 CUR 590.009(0)(3Xa).Plass Mich copies ofoertifiadontothis k.TheUealthDspaelmeutwW not use pastyonra'records.You must provide new copies and maintain a fie at your establishment, 1. 2. HEIMLR H CERTIFICATIONS: All hod smoke establidiments with 25 seats or more must have at least one trained in the Medich Maneuver on the premises at all times. Please list your employees trained•in ami procedures below attach copies ofemployee oer to this tinm.The will not use r�eeordss.. You Brost provide new copies and maintabrai#1e at place 1. 2. 3. ` 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY r'-7 ''i • PERMITS Liam Ewa=PEE PRMT . LmRBQR a wn. WH .� 075.. •RAnSERPARK MS _ / �: ,:' +1,: . a PER54 5 « . i,, -, LIF moors «: t, PER PEruari -100 Ta -►► , , VIC, .. =4344,0104 pIR,�E. PERROT. L REQUMED FEE PERMITS LICS!ffiL�EP R 1�pig PERMITS NAtUCHAJI $15 AMOUNT DUE I. S 140.00 ...4.111AtASE TORN OMR ANDaautZTEO R MDR a?matt***» /jA�j� q2 �J t9 C)44J12r�5SIV/5- l 004159-t 5 -.(244-o1 ADMINISTRATION Under Chapter 152,Section 25C,Subsection 6,theTownilfY bnowrequiedtoholdiawoceorrmewal , of any license or permit to agate a business if a parson or mammy does not have a Certificate of Waist's Campensadan Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST HE COMPLETED 4i14/1 SHRUB,OR CERT.OF INSURANCE ATTACHED OR WORKER'S COMP.AFFIDAVIT SEINED AND ATTACHED Tows of Yaemoeah taxes and liens must be paid pion to renewal at imam of your permits. PLEASE CHECK APPROPRIATELY W PAID: YES NO MOTELS AND OTHER LODGING ESTABLISSIRENTS TRANSffiNTOCCUPANClC:Format limited=°Motel arIioteluse,Tnmdaiteooep meyshall beIlud lto the tamping and statism*occupancy,o :ad "4brae.oclstsd with motel and hotel uss.Inasientoccupents must have and be able todames:wathat they manta*aprincipal place firesidenoeelsewhere.Transientoccupancy shall gess*aft to eadinuous occupancy ofnot snore then'bitty(30)days,and an wept.ofnot month=deny(90)days wads any sic(6)month period. Use at a gnat unit as a resideoce or dwelling unit shell not be considered mor ay that le sodded lo the collection of Room Occupancy liaise.as defined in MM.of 640or 330 MR 64G es amended,dud gmer*becoadde ed Transient. POOLS POOL O ININGt All swimming, and whhipooi which have been closed for the waren and be by the Hebb to opening. Coded the Health to schedule the*speedos dine 0) prior to opems&P i s People are NOT allowed*sit�areaa toil lbs pool has bean lespaesea_and opened. POOL WA'TER TUTTING:oe dllab�,and the Health and qunant be tested kr total cabins�artedy Mended plate count byaState POOL CLOSING Every outdoor In groused swimming pool must be drained or covered within seven(7)days o fclo:dog. FOOD SERVICE SEASOML FOOD SEF.VICE OPENING:. Ad food armies astablibmsats must be inspected by the Hath Department prior to opeabmg. Plus contact the Bath Depertmeattoselsehdegr laspection throe(3)days prior*opening. CATERING POLICY: Anyone who caws within the Town of Yarmouth mast way the Yaaamouth Health Depr retthe moulted Tempormy Food Service Application form 72 hours prior to the=toted went. These tem am be o ath a �heals Devotions,or from the Town's weber*at wzogyormdmolax mderHealm Department,Dewdoedable Fans. FROZEN D11831311Xth Promadesseets must heisted to the Hod*D F aceto will made iss Mete certified lah the or tb�,��sen Dome Pewit minde results me showetemu have bean met 6�e dee O• wee seating with service),mutt have prior approval from the Bond of Health. OUTDOOR COOKING: Outdoor cookie&preperation.or display of any food product bye retail or food service esaMlshm e t is pebbled. TORACOOPRODUCTISIGHT CAP A tobacco permit holder who has baited to renew his or her permit within thirty(30)days of the previous year's permit expiration date is considered art expired license,and the tobacco ikons.cap is reduced. NOTICES Permits ransummilyfrom January 1 toDsontbox3l.TUT YOURRXSPONSIBELTTY TOREI'URN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED PEES)BY DEQ 15,201& ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT.MOTEL OR POOL(i.e.,PAINTING,NEW EQUIPMENT,EEC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OP HEALTH PRIOR TO COIDdENCEIVENT. RENOVATIONS MAY REQUIRE A SITEPLAN. DATE: Ain/ SIGNATURE: x 12A PRINT NAME&WILE: Zted±L. Bartel ace- r rrR manna • : K►a61tWr ' TOWN OF YARMOUTH BOARD OF HEALTH (14. 72019 • ifiltt APPLICATION FOR LICENSE/PERMIT -2019 + sem * Please complete form and attach all necessary documents by DecemherW Mdf T NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER I5'. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Ii r Sl r»:n,`►,,Y7 S TAX ID: 64 LOCATION ADDRESS: 641 rl v3•14 ( % ri'trot'÷ TEL.#: q • 3b2.352,5 MAILING ADDRESS: Na rwelo For+, ✓nA 0?-b7S E-MAIL ADDRESS: Marla q .y►r�4•p ',‘ce...}cwc�gwicti f.coe-v OWNER NAME: yG I k .S co A-H C°o tbo M t N M —1t?-U 5T" CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: (Yl c }->4 n Le DR Q a ei rola on r TEL.#: 5.073 3k2.3 S 35 MAILING ADDRESS: Co ;n C�rr.21 tNM(r • F1- AbH- MA 07-675 1 l 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 tile-certif cation._to this form 1. MCA CAUQj niCenC 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 off business. 1. Mr Inctn Leo- 2. i�i C IO;�� &W2 3. -4'L'c(j,1 S1YV 0%nd S 4. (NA c C ka•e I T\' k)i'4 ,S FOOD PROTECTION MANAGERS - CERTIFICATIONS: 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. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. 1. 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. 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. F 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# 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 2,,SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: - LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $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. 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 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 CAFÉS: 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: 01i7 SIGNATURE: i ., �) jv / 1 PRINT NAME&TITLE: ,,,y_ r - �+ L- . ( l c{ 'I apace, Rev. 10/23/18 ,,..,..itt, KINGWAY-01 LMCCARTHY '4RDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/17/2018 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 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). CONTACT PRODUCER ' PHONE FAX Rogers&Gray Insurance Agency,Inc. (ac,No,Ext)_(800)553-1801_ i(A/C,No):(877)816-2156 434 Rte 134 E-MAIL mail ro erS ray com South Dennis,MA 02660 ADDRESS:_._ @ g 9 y• INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Scottsdale Insurance Company 41297 INSURED INSURER B:Commerce Insurance Company 34754 Kings Way Condominium Trust INSURER C:Greenwich Insurance Com'an 22322 64 Kings Circuit INSURER D:Pennsylvania Manufacturers'Association Ins.Co. 12262 Yarmouthport,MA 02675 INSURER E:Atlantic Specialty Insurance Company 27154 INSURER F:International Insurance Company of Hannover SE 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. ADDL SUER POLICY EFF POLICY EXP_ ILTR TYPE OF INSURANCE1NSDD_ POLICY NUMBER _IMMIQQJYYYYI,IMM/DD/YYYYl LIMITS A X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE 1$ 1,000,000 CLAIMS-MADE X OCCUR CPS3032189 12/15/2018 12/15/2019 DAMAGE TO RENTED 100,000 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 X POLICY jla LOC PRODUCTS-COMP/OP AGG $ 2,000,000 _ OTHER: $ B AUTOMOBILE LIABILITY (Eaaide LIMIT $ 1,000,000 ANY AUTO BHNCQM 02/18/2018 02/18/2019 BODILY INJURY(Per person) $ OUTOSWNED AU ONLY TOS X SCHEDULED BODILY INJURY(Per accident) $ A E� ON WN p PROPERTY DAMAGE X AUTOS ONLY X AUTO OY (Per accident) $ $ C ! X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 25,000,000 EXCESS LIAB CLAIMS MADE PPP7464842 12/15/2018 12/15/2019 AGGREGATE $ 25,000,000 _ DED X RETENTION$ 0 . $ D WORKERS COMPENSATION PEATUTE 0T Y/N H_ AND EMPLOYERS'LIABILITY 2018010981647Y 12/15/2018 12/15/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ FFICER/MEMBER EXCLUDED? N/A 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DISEASE-POLICY LIMIT $ 1'000'000 DESCRIPTION OF OPERATIONS below E Excess Earthquake 790-02-45-78-0001 12/15/2018 12/15/2019 Bldg&BI 10,000,000 F Commercial Property FAI7ESP2751-10225 12/15/2018 12/15/2019 Blanket Limit 100,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 129 Building,456 Unit Condominium Association Property is subject to$25,000 deductible;$25,000 Windstorm/Hail deductible Ordinance or Law Coverage: Coverage A-Loss to Undamaged Real Property:Included Coverage B-Demolition-10%of Building Value` SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION , SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Insurance Purposes ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ( :);:r4€2. Za4A.A.----------- ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID:KINGWAY-01 LMCCARTIOY -,'''".1681101 LOC#: 0 ACCPRIY ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Rogers&Gray Insurance Agency, Inc. Kings Way Condominium Trust 64 Kings Circuit POLICY NUMBER Yarmouthport,MA 02675 SEE PAGE 1 CARRIER NAIC CODE SEE PAGE 1 SEE P 1 EFFECTIVE DATE:SEE PAGE 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/LocationsNehicles: Coverage C-Increased Cost of Construction-10%of Building Value* Coverage D-Increased Business Income-10%of Building Value* *Subject to$2,500,000 per occurrence for B,C,and D Flood-$2,500,000 Limit,$100,000 Deductible Earthquake-$2,500,000 Limit,$100,000 Deductible Equipment Breakdown-$100,000,000/breakdown; $10,000 ded-Liberty Mutual Fire Ins Co ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD