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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PERNHT 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 ppaaccket. NOTE:ALL BUSINESSES WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER Ir. ESTABLISHMENT NAME: Flit i rubra IL7 /1h1✓Wh4l)✓1 J TAX ID: / LOCATION ADDRESS: I d ti 7 (24 Ai -11.TO titlei i4'N- TEL.#: So -3I11-6-6 yV MAILING ADDRESS: //(o Gd•ATP2got,SE E-MAIL ADDRESS: i2.A-PVTF () GosCAST. r OWNER NAME: CORPORATION NAME(IF APPLICABLE):RYM' ?4M 1 Ly 4"...iFirt PA/t MANAGER'S NAME: P T i CAmPaF . TEL-#: 50$- -/YVO MAILING ADDRESS: S 1 li2*1 'FARy1 R D yAk at o. r p-R i m A-- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated I Pool Operator(s)and attach a copy of the certification to this form. .< I 1. 2. -- I 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: 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 1a1 C,0 // /S�� 2.At PERSON IN CHARGE: v Each food establishment must have at least one Person In Charge(P C)on during hours of operation. l�°►� i 6 sitat Ses— 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)(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. 140.e4er (;%f/ LP764,29 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# (319 -H-o,30Z-O(p OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CARIN $55 __MOTEL $110 INN $55 —CAMP $55 _SWIMMING POOL$1 t0ea. =LODGE $55 TRAILER PARK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE P IT#8 LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LO-100 SEATS $125 1 CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 'COMMON VIC. $60 WHOLESALE $80 RETAIL SERVICE: =RESI).KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 ..ft. $50 >25,000sq 8. $285 VENDING-FOOD$25 —<25.M 11 sq.ft. $150 -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 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)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 tiling 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.yarnouth.maus 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 13,2019. ALL RENbVATIONS 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 RE UIRE A SITE PLAN. DATE: 'f- / 3 / SIGNATURE: PRINT NAME TITLE: kir r C�w7ol� t 1 <41 Rev.10115/19 Workees Ciarrioensation and Flab er's t iabtlitv Police Ain6UARD Insurance Company-A Stock Co. Berkshire 11at11away Policy Number iC9952s9 InsUranCe r,../' GUARDCompanies aneavaIVCCI 1112 to [t 7 ] Policy Information Page [1 Named Insured Maiilking Address A ency amity Arh i3MACKINAW UNDERWRITERS INC: 116 Wart use u Road NEW ENGLAND BUS OR t urne,MA 02532-3867 SUITE 110 Andover, MA 01810 Agency Code: MATPAA1O i a Federal Employer's ID Insured Corporation Risk ID Number 917565287 P [ LocatlonsonPolicy -See Extension of Information Page-Schedule of Locations rai2) Pohcir Period From December 31,2018 to Dec.ember31, 2019, 12:01 AM,standard time at the k +red's matting address. 1 E3) Coverage ,R A. Worms'Compensation Insurance-Part One of this policy applies to the Workers'Compensation Law of the following states: Massachusetts,Rhode Island B. Employer's liability Insurance-Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability ander Part Two are: Bodily Injury by Accident-each accident $500,O00 Bodily Injury by Disease-each employee $500,000 Bodily Injury by Disease-policy limit $500,000 C. Other States Insurance-Part Three of this policy appy to all states,except any state listed in item[3]A.and the states of North Dakota, Ohio,Washington,and Wyoming. D. This Policy includes these endorsements and schedules: I See Extension of Information Page Schedule of Forms [4] Premium i The Premium Basis and,therefore,the premium will be determined by our Manual of Rules, ' Classifications,Rates,and Rating Plans. Ah required information is subject to verification and change j audit. (Continued on another page) ri I i t TotalEstimated P�premium . $ 30,057 Total Surr+,g�esj $ '` 1,060.00 Total Estinaated Cost $ 31,117.40_ r, -1= Information Page RYWO395289 WC WOODIA Date :11/26/2018 ate Issuing Office:PA).Sox A-N,IS S.`Rivers WMooseSorre,PA 15703-0020 0 orvow.guitrCLOOns Worker's �EatL�iry�► Am ARD ran Company-A Stock Co. 11 Berkshire H t awfa l Policy Number RYWC995289 Insurance GLIARD Companies Rcutewal of l No. 28731 Policy ration Page Extension of Information Page Schedule of Locations 42) 200 Main Street,Buzzards Bay,MA 02532 (12/31/2018- 12/31/2019) (1.3) 441 Main Ste,Hyannis,MA 02601 (12/31/2018-12/31/2019) (L4) 1067 Rte 28,South Yantnouth,MA 02664(12/31/2018- 12/31/2019) (t.5) 115 New State Hwy,Raynham,MA 02767 (12/31/2018- 12/31/2019) (1.6) 1170 Malt Street,Mills,MA 02054(12/31/2018- 12/31/2019) (18) 23 Town Hall Sq ,Falmouth,MA 02540 (12/31/2018- 12/31/2019) (19) 19 Cl lt Ave ,Oak Bluffs,MA 02557(12/31/2018- 12/31/2019) (L10) 268 Thames St, Newport,>RI 02840(12/31/2018- 12./31/2019) (111) 769 Lyannough Road,Hyannis,MA 02601 (12/31/2018- 12/31/2019) (112) Cape Cod Inflatable Park,512 Route 28,Yarmouth,MA 026 (1018- 12/31/2019) (113) Cape Gadder Resort, 1225 Iyannough Road,Hyannis,MA 02601(12/31/2018- 12/31/2019) { SaUSIAL/ USE Page_2- InabrelatIon Page MCA :RYW 995289 WC 1A Date ±11/2601$ MANOTE Issuing Orator P.O.Box A-44,16 S.River Street,: Barre,PA 18703-0020`+www g • itG+GPRE1 CERTIFICATE OF LIABILITY INSURANCE DATE'MW°°"' ' 513!2019 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 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 John McLaughlin Agy PHOttE FAX 828 Lynn Fells Pkwy (NC.IL No,Ext►:781-665-2775 (Arc,Not 781-665-0295 Melrose MA 02176 ADDRESS: info@mdaughlinins.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Company 34754 INSURED RYANF-1 INSURER B:StarStone National Ins.Co. Ryan Family Amusements, Inc. Attn: Mike Crowley INSURER C:Guard Insurance Group 116 Waterhouse Road INSURER D:Everest National Insurance Corn Boume MA 02532-3867 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:981779816 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 POUCY EFF POLICY EXP LTR INSR WIfD POLICY NUMBER IMMIDWYYYYI (MM/DD/YYYY) UMITS D X COMMERCIAL GENERAL LIABILITY R/O SI8ML01505-181 5/1/2019 5/1/2020 EACH OCCURRENCE $1,000,000DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000 X LIQUOR LIAB MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 _ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: Liquor $1m/1m A AUTOMOBILE UABIUTY BDPRLQ 4/102019 4/102020 COMBINED SINGLE LIMIT $ (Ea accident) 1,000 000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS , AUTOS X HIRED AUTOS X AUT SWNED PR((POPERTer nt)DAMAGE B X UMBRELLA UAB X OCCUR 70531N183AU 5/12019 5/1/2020 EACH OCCURRENCE $5,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $ • DED X RETENTION$10 000 _ $ C WORKERS COMPENSATION RYWC995289 12/312018 12/312019 PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVENIA El.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 O Property R/O SI8ML01505-181 5/12019 5/1/2020 Building $2,732,400 Bus.Pers.Prop. $250,000 Bus.Inc. $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addblonai Remarks Schedule,may be attached if more space Is required) Evidence of Insurance 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 POUCY PROVISIONS. Town Hall 1146 Route 28 AUTHORIZED REPRESENTATWE So.Yarmouth MA 02664 97) ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD