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HomeMy WebLinkAboutApplication and WC ' • TOWN OF YARMOUTH BOARD OF HEALTH , r �� APPLICATION FOR LICENSE/PERMIT-2020 c > �',, *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 WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER IP. s, ESTABLISHMENT NAME: ti ~J/ � t A4 .. TAX ID: tIL..rLOCATION ADDRESS: c- - Q (4 t , ,4 �J TEL.#: . ,�� ,)-- MAILING ADDRESS:ter 1-tm00.14,.e, t vt1 a- E-MAIL ADDRESS: Q � ,L„'„ ��+ h€4 OWNER NAME: II'1d�; .- L,�A�1'1/4 ��ea. in a_ CORPORATION NAME(IF APPASLE): MANAGER'S NAME: 4-- lc4. c (,i.a. a tn4 4 TF,L.#: 7T y. -19 Cf-1 9-73 MAILING ADDRESS: SA' 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 the certification to this form. I. 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 .. O years'records. You must provide new copies and maintain a file at your place of business. (''. 1. - e-J' 1. 7 1 3. 4. it c t 1 H cep ,. FOOD PROTECTION MANAGERS-CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food ----i 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. 7A, 101 You must provide new copies and maintain a file at your establishment. , I. 'LU-Q^ V3 c cit_ci-. 2. 7. PERSON IN CHARGE: Eachfoodestablishment must have at least one Person In Charge(PIC)on site during hours of operation. i� l o ' pp t L �. � �. h a- 1�lz 2 21 ALLERGEN CERTIFICATIONS: • �: - All food service establishments are required to have at least one full-time employee who has Allergen certification, . I 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.A---a ., Q� ab-P 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. gOr \c 1 -(\ c4 ) 2. 3. 4. RESTAURANT SEATING: TOTAL# 130 't,--63te _O OFFICE USE ONLY ��+0 LODGING: LICENSE REQUIRED Flim PERMI # LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED Flit? PERMIT B&B $55 CABIN $55 MOTEL. $110 INN $55 CAMP $55SWIMMING POOL$110ea. _LOIX;E $55 TRAILER PARK $105 - WHIRLPOOL $110ca. FOOD SERVICE: I JJCENSL REQUIRED PEE PERMrr# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FIT. PERMIT 1_0-100 SEATS $125 TO-424 CON'T'INENTAL $35 NON-PROFIT $30 >100 SEATS $200 $60 COMMON VTC. WI IOt,ESALE $80 RESID.KrrCHEN U0 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM1'1 # LICENSE REQUIRED FEE PERMIT# _-50 sq.l). $50 >25.000 Nil. $285 VENDING-FOOD $25 25.000 sq.11. $150 _FROZEN DESSERT $40 - I T'OBAC'CO $110 NAME CHANGE: S15 AMOUNT DUE = S J 6 OO *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION r 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 pri 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 arc 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 TILE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE,Q��UIIREA�SII E P I. DATE: it S11,1 SIGNATURE:��I—ef- PRINT NAME&TITLE: Al c: via, h0 6-(' /jt 4' Rev.10/15/19 DATE(MWDD/YYYY) AC'Ro CERTIFICATE OF LIABILITY INSURANCE 11/14/2019 THI CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CEIIFICATE 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 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 CONTACT NAME: Automatic Data Processing Insurance Agency,Inc. PHONE FAX MX.No.Ext): (A/C,No): E-MAIL ADDRESS: 1 Adp Boulevard INSURER(S)AFFORDING COVERAGE NAIC S Roseland NJ 07068 INSURER A: Employers Preferred Insurance Company 10346 INSURED INSURER B: INAHO JAPANESE RESTAURANT INSURER C: 157 RTE 6A INSURER D: INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 1310073 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 POUCY EXP LIMITS LTR INSD WVD POUCY NUMBER (MMIDDIYYYY) (MMIDWYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCED $ AGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- LOC PRODUCTS-COMP/OP AGG $ 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 UAB OCCUR EACH OCCURRENCE _ $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION x PEATUTE ETH AND EMPLOYERS'LIABILITY A ANY OFFIC R/MEMBEERR EXC UDED?�� YYN N/A N EIG248569602 05/02/2019 05/02/2020 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Ad Hdon l Remarks Schedule,may be attached It more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town Of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Main St AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACoRI® CERTIFICATE OF LIABILITY INSURANCE DATE(M DD"9 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 Elizabeth Bortone C&S Insurance dba F.M.Walley Insurance Agency ttPAH/CO,NNEo ): (781)326-8383 Ftic,AX No): (781)326-8387 475 High Street A- Lss: ebortone@walleyinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Dedham MA 02026 INSURER A• Hospitality Mutual Insurance Company INSURED INSURER B: Aida&Yugi Watanabe INSURER C: DBA Inaho Japanese Restaurant INSURER D: 157 Main Street Rte 6A INSURER E: Yarmouthport MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 2019 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 NSD' UBR r POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDDIYYYY) (MM/DD/YYY1f) X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE (EaEoccui RENTED10$ 100'000 — MED EXP(My one person) $ 5,000 A 00101200GL 04/20/2019 04/20/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 XPOLICY n ECT n LOC PRODUCTS-COMP/OPAGG _ $ 2,000,000 OTHER: $ AUTOMOBILE UABIUTY 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 UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER CM-1- AND EMPLOYERS'UABIUTY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE n N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Per Person $1,000,000 A Liquor Liability 00101202LL 04/20/2019 04/20/2020 Per Occurrence $1,000,000 Aggregate $2,000,000. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K more space la required) 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 Main Street Route 28 AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 '('rot �"J1;i tv.. 1 11 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD