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HomeMy WebLinkAboutApplication and WC TOWN OF YARMOUTH BOARD OF HEALTH , i v„,,-- s ill- APPLICATION FOR LICENSE/PERMIT-2020 -„1 *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 WITHLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15g. ESTABLISHMENT NAME:-i h2_ VattlYIG1t.,tr 1- t/--e-- TAX ID• LOCATION ADDRESS: 33S Y-nGur1 S-} -#-. TEL.#: MAILING ADDRESS: E-MAIL ADDRESS L rr Yt'Vy,,,t ,P r e tea+ 1 - SL wry" OWNER NAME: CL 1(GL -Q 1-s CORPORATION NAME(IF LICABLE): t..<2_! n - s S- MANAGER'S NAME: r1CI,-c, 3e r mop t ,t,C_ TEL.#:5O T)I- Sl W MAILING ADDRESS: rn•P_ _ xl POOL CERTIFICATIONS: -< m The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated r- 0. Pool Operator(s)and attach a copy of the certification to this form. m C7; 1. 2. m arn Pool operators must list a minimum of two employees currently certified in standard First Aid and Community ca 0 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 fde at your place of business. 1. 2. 3. 4. r .., 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. 4 You must_provide new copies and maintain a file at your establishment. 1. �X.t.t1 f 2. PERSON IN CHARGE:/ Each( food establishment must have at least_ one Person In Charge(PIC)on site during hours of operation. aio 1. 01(\61 r Ce \Atli r l C- 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. I. (2cti ;/ L.6p/Q ,[./e-- 2. HEIMLICH CERI11•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. f a,irSCP`PA +VJ�'-tiA- 2. 3. 4. RESTAURANT SEATING: TOTAL# 06W-14~0332-0 OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT S LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 TINN $5S CAMP $55 SWIMMING' POOL$1IOea. LODTRAILER PARK $105 WHIRLPOOL $I10ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT# LICENSEUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 1>100 SEATS $200 __NWT.Ca .COMMON VIC. $60 Z O•–()37 WHOLESALE $80 RETAIL SERVICE: —RESID.KITCHEN $80 LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMITS LICENSE REQUIRED FEE PERMIT <50 sq R. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $150 ^FROZEN DESSERT$40 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $2,0.00 *****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 ENSATION 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(3©)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 640,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 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 Member 31. ITIS 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 APPRO ' • BY 1)HE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ S'' PLAN. DATE: l\/26114 SIGNATURE: PRINT NAME& I FILE: CoCc(4 24rc' \.S o n2( Rev.10115/19 y Act CERTIFICATE OF LIABILITY INSURANCE DATE(M1p! 112019 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(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: STANDISH INSURANCE GROUP INC. PHONE 714.283-4425' TFAX_.___ _.i 114.783-:42443" ---- 303 COURT STREET UNIT 1B ��'EI .________ .---_ c,Not---- . —._ ,qEtt ANDYR@STANDISHINSURANCE.COM PLYMOUTH,MA. 02360 --__ _- ________.__ -7- INSURER(S)AFFORDING COVERAGE —_----;_-- NMC# INSURER A:Lloyds Of London , INSUREDLIBERTY MUTUAL i INSURER e: KOUNADIS ENTERPRISES CAPITOL SPECIAL ___._ __.. iNSURERc ;_. THE YARMOUTH HOUSE INSURER a _----...- 335 MAIN ST : i _ INSURER E WEST YARMOUTH MA 02673 �..y—_.----.-__-- _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. ADM SIIBRi PO4ICY ERF POLICY EXP TYPE OF INSURANCE LTR i WII11.„ POLICY NUMBER i($IINDIYYYY) Ri1MIDDlYYYYJ LIMITS X , COMMERCIAL GENERAL LIABILITY l DSCPK0543 4/01/2019! 4/01/2020 EACH OCCURRENCE — $ 10O 0,0 00 r---t A I ... CLAIMS MADE i OCCUR t PR�MISEs(Ea occurrence) s _100,000 MED EXP( one person) IS ____10000 l GE PERSONAL&ADV INJURY 1$ 1000000 1/'L AGGREGATE LIMIT APPLIES PER: i I GENERAL AGGREGATE $ 20,000,000 I POLICY L_ 1 PRO- ' LOC -' --- ---- - , _ 1 JECT _-._� I PRODUCTS-COMP/OPAGG i$ I OTHER' I t i$ 1 AUTOMOBILE LU181LnY t i `COMBINED SINGLE LIMIT $ n 1 ANY AUTO I BODILY INJURY(PerI person) $ • OWNED I j SCHEDULED 1 AUTOS ONLY _I AUTOS I !BODILY INJURY(Per accident)I$ HIRED 1 NON-OWNED ! i— _-_-___ ___ --�— I i (PROOPERTY DAMAGE' !$ AUTOS ONLY k...._4 AUTOS ONLY LLppr accident) ii 1 I I { i- i S UMBRELLA UAB . .� I l OCCUR EACH OCCURRENCE I$ I (EXCESS - .B I : CLAIMS-MADE !— I I Z AGGREGATE ;$ OED I 1 RETENTIONS $ WORKERS COMPENSATION WC5318616095019 1 !PER OTH I AND EMPLOYERS LIABILITY I9T_UTE i_.-1€'R yANY PROPRiETOR/PARTNER/EXECUTIVE YIN 5/01/2019 5/01/2020 —.----- _-___-- B ;OFFICER/MEMBER EXCLUDED, I N/A I E.L.EACH ACCIDENT y$ 500 000, I(Mandatory in NH) I t E.L.DISEASE-EA EMPLOYE $ _ 500,000 it yea describe under — i DESCRIPTION OF OPERATIONS below ti ! E.L.DISEASE-POLICY LIMIT $ 500,000 C LIQUOR LIABILITY CS 1800192502 4/01/2019 ( 4/01/2020 i $1,000,000 PER OCCUERENCE ( I$2,000,000 GENERAL�GGREGATE f 4 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I more space M required) CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 RTE 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SOUTH YARMOUTH MA 02664 AUTHORIZED REPRESENTATIVE I19811-20 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of A ORD