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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH APPLICATION FOR LICENSE/PE ' -20 I e NOV 1 5 ZU 11 * Please complete form and attach all necessary sod j: + n sT-Av s . z� a s%19. Failure to do so will result in the returnkpf your appli h‘ f:; e . NOTE:ALL BUSINESSES WITH LIOUOR LICENSES MUST RETURN.FO '•`NOVEMBER 15th. ESTABLISHMENT NAME: A .6)04 E Lc4 cti"5 e) TAX ID: LOCATION ADDRESS: /9 64/) 7 4f(ous - TEL.#:5)P- ,39Y-3 (3 MAILING ADDRESS: SAIY/E E-MAIL ADDRESS: R-LSC?Q /ydT®nA/C; C-Ohl OWNER NAME:..2-Q A K RuSS© CORPORATION NAME (IF APPLICABLE): 111/94(// /i) MANAGER'S NAME: T#T T/hC� :�ic. P a y f TEL.#: 13 -c661 MAILING ADDRESS: 6O6 O',</,1 ._ tom-`/MnpoTh' 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. 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 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. 1. `!AfJE i Y 2. ez 2 Y /✓e. /0E4CL)' 5 Tow K. ed5S6 PERSON IN CHARGE: Each food establishment must have at least one Person In Charge(PIC) on site during hours of operation. 1. z'ihJ&T � �L' Y _ 2. /MOLLY lYiJ/PjV I ALLERGEN CERTIFICATIONS: 4' Cot. ii7Y�^ 3° /J� V P0556 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 andnmaintain a file at your establishment. 1. So f/i �(JSSO 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. .D.1)/Oe7 lie .-L &iO '1 2. TONAL) P0.5 3. eld L&/ M c. g_b)-{'/ 4. RESTAURANT SEATING: TOTAL# Cil 13 -It--str zi-66 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55$55 —C� $55 MOTEL $110 $55 _SWIMMING POOL$110ea. LODGE $55 _TRAILER PARK $105 —WHIRLPOOL $110ea FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I 0-100 SEATS $125 20-025 CONTINENTAL $35 _NON-PROFIT $30 >100 SEATS $200 T COMMON VIC. $60 20--0 O 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 = $ f8S; OQ *****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 {i 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 W 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 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 QUIRE A SITE LAN. DATE: //— _/ 9 SIGNATURE: C PRINT NAME&TITLE: •.1�4� V K USSO M657 ii)61C.)/ Rev.10/15/19 ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 11/06/2019 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 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 C43 TACT Ray Travers The Oceanside Insurance Group PHONE (508)771-1660FAX,No): 411 Route 28 (508)775-1135 L Excl. ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# West Yarmouth MA 02673 INSURER Scottsdale Ins Co. INSURED INSURER B: Twin City Fire Insurance Company MAAM Inc.,DBA:Longfellows Pub INSURER c: 182 Old Town House Rd UnitA INSURER D: INSURER E: West Yarmouth .MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1911607350 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. LTR TYPE OF INSURANCE ,Ip WVD POLICY NUMBER SR ADDPOLICY EFF POLICY EXP(MMIDD/YYYY) (MMIDD/YYYY) WAITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE XI OCCUR PREMISES(Ea occurrence) $ 100,000 _ MED EXP(Any one person) $ 5,000 A CPS3269313 10/19/2019 10/19/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY n jEa n LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 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 UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION ul PER OTH- AND EMPLOYERS'LIABIUTY �I STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN El.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? I i 1 NIA 08WECCB9655 02/23/2019 02123/2020 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 100.000 describeIf under E.L.DISEASE-POLICY UMIT $ DESCRIPTION OF OPERATIONS below 500.000 Each Occurrence 1,000,000 Liquor Liability A CPS3269313 10/19/2019 10/19/2020 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddMlonal Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsement of the policy. 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. AUTHORIZED REPRESENTATIVE ID 1988-2015 ACORD CORPORATION. All rights reserved. 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