The URL can be used to link to this page

Home My WebLink AboutApplication and WC i'lliri- \\ TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERMIT-2020 *Please complete form and attach all necessary documents by December 13.2019. Failure to do so will result in the return of your application packet NOTE:ALL BUSINESSES WTTII LIOUOR LICENSES MUST RETURN FORMS.BY NOVEMBER 154. ESTABLISHMENT NAME: , ..4._) e-..x.- '' .- v•A.Y., -.)-ei\. TAX ID: LOCATION ADDRESS: 1-\l " a"\--4-."4-:‘04,- --C ...le._ >,V 4V‘4.,,._.--\TEL.#: MAILING ADDRESS: \---7C) VA,*JI\W1/41,4- ,.Y.‘"'<s4 (1-6, 0 5`..--(71AL7 1 \AAR- E-MAIL ADDRESS: "t"\'''‘ S (..._)C..4-.1- ION--) VV\,‘+est• (.0 OWNER - OWNER NAME: \NI.\L cZ Cl.\N‘,. CORPORATION NAME_OF APPLICABLE):‘<--tk-C2C-14' -, -. 4 _ MANAGER'S NAME:``... .""-e4e6_,A ., IC, 'Nat-C)C1..Q iNk_A) TEL.#: 3 IA :S CO t\'' LcOS 4 MAILING ADDRESS:'Mo l c c,,-\. 'i 's\-....-)e ‘ C.),-)'14, 'PR POOL CERTIFICATIONS: 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 mtification to this form. 1. .---""- 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Community i .= 7) Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the Et C3 m employees below and attach copies of their certifications to this form,The Health Department will not use past r C) rN years'records. You must provide new copies and maintain a file at your plaus ce of b ' s. H —, -• ri 4. , , 1 , 1 -- ,...." i FOOD PROTECTION MANAGERS-CERIFICATIONS: I 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. 1-4-,cio ..,,,,......4,.. You must provide new copies and maintain a file at your establishment. 1. •Z•.‘ -'\.'-'0\(._41, 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. \ 1S ' o c%41/4-AA)2. \k _i-k_kk. ALLERGEN CERTIFICATIONS: ikrr-Sot; 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)(3Xa). 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 , .-e...4 \\\ %\i'LYCLJC-- 2. \ig\IVN••-i LA-4\ra,)\''73 \ 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 ,i•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. \lc_ You must provide new copies and maintain file at your place of business. t 1. "-te. \\ tk.--!",N't '\C 2. 3. 4. RESTAURANT SEATING: TOTAL# 6 0 N--F-- A-0-320---0(0 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT* B&B $55 CABIN $55 MOTEL $110 INN $55 —CAMP $55 SWIMMING POOL$110ea. —LODGE $55 —TRAILER PARK $105 WHIRLPOOL $110ea. — FOOD SERVICE: LICENSE REQUIRED FEE P 4 LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS j_0-100 SEATS $125 0* I Se CONTINENTAL $35 , _,.,. NON-PFt0FIT $30 >100 SEATS $200 'COMMON VIC. $60 1.0 001 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN$80 LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT It LICENSE REQUIRED FEE PERMITS <50 ,It. $5017 >25,000 sq.& $285 VENDING-FOOD$25<z,o o sql. S150 ----- _FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 185.00 *****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 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) 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 opined 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 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 13,2019. 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 Sl'1 G '> DATE: l I — t ' (_( SIGNATURE: J J PRINT NAME&TITLE:''A\N l.l`\A Stj,3 (2);_e_")v\jos Rev.10/15119 J l A D CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDM YY) 11/20/2018 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 NAme Kris Kopreski Mark Sylvia Insurance Agency,LLC r jcON Fxth (508)957-2125 F,vc.Nol: (508)957-2781 404 Main Street A DDR ESS: mark@marksylviainsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Centerville MA 02632 INSURER A: Farm Family Casualty Insurance INSURED INSURER B: Scottsdale Ins Co The Grump Incorporated Dba Sweet Tomatoes Pizza INSURER C: 170 Hollingsworth Road INSURER D Osterville,MA 02655-2153 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 ADDL SUBR POLICY EFF POLICYVD EXP LIMITS LTR INSn WPOLICY NUMBER (MMMI IDDIYYYY) (MDDPYY YY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED CLAIMS MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 A N N 2001X1553 11/30/2018 11/30/2019 PERSONAL SADVINJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE. $ 2,000,000 PRO X POLICY JECT LOC PRODUCTS-COMP/OP AGO $2;000,000 OTHER $: CMBINED AUTOMOBILE LIABILITY EataccidenSINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ . UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER ER TUTE AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? Y N/A N 2001W8131 3/4/2018 3/4/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under E.L..DISEASE POLICY LIMB $ 1,000,000 DESCRIPTION OF OPERATIONS below General Aggregate` 12,000,000 Liquor Liability Each Occurance $1,000,000 g N N CPS2992904 11/30/2018 11/30/2019 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Pizza restaurant 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES,BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth - MA 02664 . Fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MWDD/YYYY) ACGRD CERTIFICATE OF LIABILITY INSURANCE 11/20/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES.NQT 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 1NSURER(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, sub1ect to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not qonfer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Kris KOpreski Mark Sylvia Insurance Agency,LLC PHONE ' arXc.No): (508)957-2781 y 9 cY, �Alc No Fxty (508)957-2125 404 Main Street a niiESs: mark@marksylviainsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Centerville MA 02632 INSURER A: Farm.Family Casualty Insurance INSURED INSURER B: Scottsdale Ins CO The Grump Incorporated Dba Sweet Tomatoes Pizza INSURER C 170 Hollingsworth Road INSURER D: Osterville,MA 02655-2153 INSURER E: INSURER F: COVERAGES 1 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 NSR TYPE OF INSURANCE INSn ywn POLICY NUMBER (MMIDDIYYY'Q (MM!DDIYYYYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A N - N 2001X1553 11/30/2018 11/30/2019 PERSONAL&ADVINJURY $ 1,000,000 GEEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY PROT- LOC PRODUCTS..COMP/OP AGG $ 2,000,000 JEC $ COMBINED SINGLE LIMIT $ OTHER: AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _'FAUTOS PROPERTY DAMAGE $ HIRED NON-OWNED $ AUTOS ONLY _ AUTOSjONLY (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION R OTH- ST TUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? y N/A N 2001W8131 3/4/2018 3/4/2019 E,L.DISEASE-EA EMPLOYEE $ 1,o0oA (Mandatory in NH) 00 If yes,describe under DESCRIPTIONE.L.DISEASE-POLICY LIMB $ 1,000,000: OPERATIONS below OF General Aggregate $2,000,000 Liquor Liability N N CPS2992904 11/30/2018 11/30/2019 Each Occurance $1,000,000 B DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101 Additional Remarks Schedule,may be attached If more space is required) Pizza restaurant 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN. ACCORDANCE WITH THE POLICY PROVISIONS: Town of Chatham 790 Main Street AUTHORIZED REPRESENTATIVE .,, - • I Chatham MA 02633 fax: Email: ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD