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Home My WebLink AboutApplication and WC t s A21ACk4l RECEIVED YARMOUTH ARD OF HEALTH �- + , APPLICATIONTOWN OF FOR LICENSE/PERMBOIT-2020 NOV 2 2?Olq * Please complete form and attach all necessary documents by Dece be 019. Failure to do so will result in the return of your application pa . - ' PT NOTE:ALL BUSINESSES/WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 1 ESTABLISHMENT NAME: / hi/roti i 4,,' A7e77C/Cr d Jrs�,�t TAX ID: LOCATION ADDRESS: L)/o Winim fT tom/ Lyenikid,it .ria o?r-73TEL.#: 50g-sal. 4116 MAILING ADDRESS: E-MAIL ADDRESS: pry cc2,, ,, OWNER NAME: b0-014_ LD S . /,.Vii ® ' ga;«� CORPORATION NAME (IF APPLICABLE): , P)a t,. i.'. MANAGER'S NAME: TEL.#: SA Li y5, o 2 y,1 MAILING ADDRESS: 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 ach-a-eopy-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 yearsrecords. 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.vQf� 1. r ..vd LYc2 2. M0 �oU 2 f/(cJ1 ( 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. C 1. -�ec�eirICC) CICA.-CS 2. J Quit SO 00'1 0 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# 113. P.OW- 1--3C,( -O3 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 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 i>100 SEATS $200 7-0-639 I COMMON VIC. $60 7.0 -030 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 = $2400.00 *****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 p ' 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 shalt 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.yannouth.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 COMMEN EMENT. RENOVATIONS MAY REQUI A SIT . DATE: // SIGNATURE: PRINT NAME&TITLE: D l e:2 ( '/1.e I'[ Rev. 10/15/19 1 11/22/2019 10 : 06 From : 5097778899 Anderson Lampe, PS Webfax Page : 1/1 ACAPUI9 OP ID: DI) ,4 v" CERTIFICATE OF LIABILITY INSURANCE DATE(M10/18/2019 8/2/201rY) 019 . 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 pollcy(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 781-247-7800 Farm.Evan Tobasky Brown&Brown of Mass. LLC PNS 781-247-7800 FAX 781-444-0090 dba Rodman Insurance Agency (AIC,No,Ext): I(AIC,No): 145 Rosemary St. Bldg.A Friss: • Needham,MA 02494-3238 Evan Tobasky INSURER(S)AFFORDING COVERAGE NAIC INSURER A:The Hartford-SCIC INSURED LaPlaya dba El Marlachl INSURER B:Wesco Insurance Co. 25011- West Yarmouth Location 705 W 7th Ave Suite A-3 INSURER C: Spokane,WA 99204 INSURER D: 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LTR MRSD,WVD 0AMIDDIYYYY) (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 08SBMAD4757 06/18/2019 06/18/2020 DAMAGETORENTED 1,000,000 PREMISES(Ee occurrence/ $ MED EXP(Any one person) $ 5,000 X Liquor Liability PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000 POLICY ,1PCT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER' $ A COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ANY AUTO 08SBMAD4757 06/1812019 06/18/2020 BODLY INJURY(Per person) $ AUTOS�EpONLY v AUUTNOpS�yyLED BODILY INJURYp (Per accident) $ AUTOS ONLY x AUTOS ON (Perr acEciidentl AM AGE S A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS UAB CLAIMS-MADE 08SBMAD4757 06/18/2019 06/18/2020 AGGREGATE $ 1,000,000 DED RETENTION$ $ B WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y 1 N STATUTE ER ANY PROPRIETORrPARTNERIEXECUIIVE WWC3426768 08/15/2019 08/15/2020 500,000 pFFgpolM�vl EXCLUDED? N I A E.L.EACH ACCIDENT $ (Maeda ory n E.L.DISEASE•EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addklonal Remarks Schedule,may be attached If more space Is required) 416 Rte 28,West Yarmouth, Mass. CERTIFICATE HOLDER CANCELLATION WESTYAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of West Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. West Yarmouth,MA AUTHORIZED REPRESENTATIVE I `/a ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD