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HomeMy WebLinkAboutApplication snd WC = TOWN OF YARMOUTH BOARD OF HEALTH 3740 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 WITH LIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 1r. ESTABLISHMENT NAME:Keel F CP_ J4 r s c_ TAX ID: LOCATION ADDRESS:68"S" Mf 1(i 6 ' .e,¢ TEL.#: ''77/—Sala--� MAILING ADDRESS �,rri Z E-MAIL ADDRESS:U r 1Gs t�7t hh t4e-r S .ru4. ��+'C.'m . cc,-/y1 OWNER NAME: V(xrtC�teil bre 5 CORPORATION NAME pip PPtICABLE): MANAGER'S NAME: I.AJh 4't�(„ TEL.#: MAILING ADDRESS: POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please listthe 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 3. 4. `� q 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. \ k1 2. RECEIVED PERSON IN CHARGE: NOV Z b o 19 Each food establishment must have at least one Person In Charge(PIC)on site during hours of operation. 1.Mtaait Ctli141.1Wt 2. HEALTH DEPT, 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. I 2. HEIMLICH CER I'Ii•'ICATIONS: 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 _ _ 3. 4. RESTAURANT SEATING: TOTAL# p r It -O32I�r OFFICE USE ONLY D"R `I J 10 LODGING: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT it LICENSE REQUIRED FEE PERMIT B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea -LODGE $55 TRAILER PARK $105 _WHIRLPOOL $IIOea. FOOD SERVICE: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT S 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 J_>100 SEATS $200 2p64 I% J_COMMON VIC. $60 WHOLESALE $80 RESID.KITCHEN$80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT II LICENSE REQUIRED FEE PERMIT II LICENSE REQUIRED FEE PERMIT S <50 ..ft. $50 >25,000 sq.ft. $285 VENDING-FOOD$25 <Bo I I sq.ft. $150 !FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $2. ,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.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 res the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert 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 APPLICATIONS)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 SITE PLAN. DATE: k.(l ( ' 1 SIGNATURE: 1�i✓� r''`te PRINT NAME&TITLE: r�K(2 ` m. 1 Je_c,I 0 k cA N A{,tei- Rev:10/15/19 , ' AC RD DATE(MMlDD1YYYY)CERTIFICATE OF LIABILITY INSURANCE 10/21/2019 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 endorsementsONTACT I KtuuLr� PRODUCER NAME__, STANDISH INSURANCE GROUP INC. PHONE 774-2814425— FAX 774,283:4243 "-....._ _wc.No Ext) INC 40)_ 303 COURT STREET UNIT 1 B E-MAIL ANDYR@STANDISHINSURANCE COM ADDRESS:.__ PLYMOUTH,MA, 02360iNSURER(S)AFFORDING COVERAGE NAIC 0..-~ INSURER A:GUARD INSURANCE GROUP INSURED INSURER B RED FACE JACKS INCINSURERC:GUARD D/B/A RED FACE JACKS INSURER D ...__..._ 585 ROUTE 28 INSURER E: WEST YARMOUTH MA 02673 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 E O..._-_-, _ OF ..____MAY. V..-_BEEN ,EDUCEOLICY EFF PIDCI. IMS.XP REIN IS SUBJECT TO ALL THE TERMS. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. LIMITS SHOWN OCY NUMBER E REDUCED HE INSURANCE AFFORDED BY THE POLICIES YIPAIO CLAIMS. HEREIN ____T EXCLUSIONS AND CONDITIONS OF SUCH POLICIES INSRI LTTYPE OF INSURANCE i iSUBR I LIMITS LTR ;INSD i WVD: 4 - 1 1,000,00 X i COMMERCIAL GENERAL LIABILITY i I REBP079489 1 8/12/20191 8/12/2020 EACH OCCURRENCE $ DAMAGE�'O€tENTED A i___ ',..,._, _.-a I i - {, PREMISES(Ea occurrence) ;5... ......... 50,000 CLAIMS-MADE ;OCCUR j } s 5000 MED EXP(Any one person) I -': 1 i PERSONAL R ADV INJURY S 1,000,000 GEN AGGREGATE LIMIT APPLIES PER: 1 ". •GENERAL AGGREGATE 5 t 2,000,000 01 POLICY ._. ,;JECT LOG RO; ! DUCTS COMP/OP AGG S______ 2,000 00 Is j 5 I OTHER COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident),.___.____ ....'_�__-- ' --- BODILY INJURY(Per person) S ;ANY AUTO i. i ..__.._ 1 ;OWNED i- "SCHEDULED , BODILY INJURY(Per accident) S ;........ AUTOS ONLY ;AUTOS - ._ _ .._.. .-__._...._. `HIRED `NON-OWNED PROPERTY DAMAGE ;$ AUTOS ONLY ...AUTOS ONLY `. _(Per accident). _ ...___...__.. UMBRELLA LIAR ' i EACH OCCURRENCE .__ !$ __..___._. OCCUR EXCESS LIAR CLAIMS-MADE; j AGGREGATE S !S DED RETENTION S I • :WORKERS COMPENSATION 6S62UB9F70437919 STATUTE_ ,m_ 0TH,_ •AND EMPLOYERS'LIABILITY Y/N 5/16/2019 5/16/2020 E L.EACH ACCIDENT S 500OOO ANY PROPRIETOR/PARTNER/EXECUTIVE [-1 'N/A B OFFICER/MEMBER EXCLUDED?(Mandatory InNH) 1 E L DISEASE EA EMPLOYEES 5QQ QQQ It yes,describen under l E L DISEASE•POLICY LIMIT'S 500,000 DESCRIPTION OF OPERATIONS below . LIQUOR LIABILITY 1 REBP079489 8/12/2019 1 8/12/2020 $1,000,000 PER OCCUR $2,000,000 AGGREGATE DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) LOCATION 1 585 ROUTE 28 WEST YARMOUTH MA BUILDING 1 YEAR ROUND RESTAURANT 10 DAYS NOTICE OF CANCELLATION , •CERTIFICATE HOLDER • CANCELLATION TOWN OF YARMOUTH SHOULD ANY-OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1146 RTE 28 ACCORDANCE WITH THE POLICY PROVISIONS. SOUTH YARMOUTH MA 02664 AUTHORIZED REPRESENTATIVE .4:11phi\ I : / ©1988-25 ACORD CORPORATION. All rights reserved ACORD 25(2 6103) The ACORD name and logo are registered marks of ACORD