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Home My WebLink AboutApplicaton and WC • �lsl � L TOWN OF YARMOUTH BOARD OF HE f if Lill APPLICATION FOR LICEN � ' " ' 1 _A �1,,••• FEB 10 2020 * ' e Please complete form and attach all nec .i = � ocun� ems ' ��s I T Failure to do so will result in the rets of your application pac e . NOTE:ALL BUSINESSES WITH LIQUOR LICENSES MUST RETURN FORMS BY NOVEMBER 154. ESTABLISHMENT NAME: rams 4- r14 S T• XIP• LOCATION ADDRES . 't ;r TEL.#: 1' S MAILING ADDRES : I a r n►l r o -7 E-MAIL ADDRESS: filar)az,eT e,rio f C-e K L)( (,t.)3 "via 1 I• C argil OWNER NAME: CORPORATION NAME APPLICABLE): MANAGER'S NAME: e h Q-' l L i(7 P/r y /)?eZ/,Y.t- evTEL.#:5o i"3&, -3535 MAILING ADDRESS:LIfel r 9 S e/if' /4;I-7 jayy1961,1A. y-441- RifI / 7 5 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 fors. 1. Michael 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.[fl e 9 hay) I--� D1 2. )Cho/ 67 0/lam e S 3. n,)1 J)(i ' ' / fr) G1-. `7f - s 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. 2. 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. 1. 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. 6o+4-SP.,15-1273-o 1. 2. 1, SP-15—tZt4-6S 3. 4. RRCTATTRANT CPATTNf• 'MTAI` ff o2 POOLs 22.0030 20—0171 a.o—act 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 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 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 REQSc A SITE PLAN. DATE:p + q + 0 SIGNATURE: /( J(f PRINT NAME&TITLE: +-I�fn e �r J Rev.10/15/19 —''1 KINGWAY-01 MCHIANO A .IRo CERTIFICATE OF LIABILITY INSURANCE DA�(MM'DD1 12!31!2018 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 Fa1tiF►CT Melissa Chiano,CRIS RogemGray,,Inc. PHONE 434 Rte 134 (AC.No,Esq:2151 FAX No):(877)816-2156 South Dennis,MA 02660 E-MAIL DRESg mchianoerogersgray com INSURER(Sf_AFFORDINGCOVERAGE-____ �$ I INSURER A.Philadelphia Indemnity Insurance Company 18058 INSURED 1INSURER B:Greenwich Insurance Company _ 22322 __ Kings Way Condominium Trust I INSURER c•AmTrust Title Insurance Company 151578 64 Kings Circuit INSURER D:Atlantic pecialV Insurance Company, 27154 Yarmouthport,MA 02675 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. I`TSRR, TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP ' INSD,WVD POLICY NUMBER MIEUDD/YYYY) BA0VDD/YYYYE I LIMITS A X COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE X OCCUR PHPK2075064 12115!2019"12115!2020 DAMAGE S1E RENTED l $ 100,000 MED EXP(Any one person)_-,._$a ._, �__ 6'000 PERSONAL&ADV INJURY 4, ,000,000 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ J X POLICY( l LOC PRODUCTS-COMP/OP AGG $ 2,000,000' OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO 1 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOSIRE� ONLY AUUTNOpSyy� BODILY INJURY(Per accident $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ B X EXCESS UAB $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 26,000,000 CLAIMS-MADE PPP7464842 1 12!1512019 12/15/2020;AGGREGATE DED C :WORKERS X I RETENTION$ 0 i -i $ COMPENSATION 1 PER 0TH- AND EMPLOYERS'LIABILITY _- -i STATUSE_ :.ER _ TWC3845337 12!15!2019 12/16/20201-_ ANY PROPRIETOR/PARTNER/EXECUTIVE I N E L EACH ACCIDENT $- 1,000,000 FICER/MEMBEggg EXCLUDED? N 1 A ( datory m NH) E.L.DISEASE-EA EMPLOY $ 1,000,000 It yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ D Commercial Property 12/15/2019 12115/2020 Bldg&BI 10,000,000 1 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached R more apace Is required) 129 Building,456 Unit Condominium Association Standard Separation of Insureds condition applies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Proof of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE E%�f� ACORD 25(2016103) ®1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD