HomeMy WebLinkAboutApp-License-Certifications TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT - 2022
* Please complete form and attach all necessary documents by December 18, 2021.
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME: Cotoiin V-Accis 140U-6 e_ TAX ID: 38 -3(1%q — 19.5
LOCATION ADDRESS:3p$ Old. M a►c\ fit. TEL.#: 50R-7bO
MAILING ADDRESS: 600-1-1, yew oU th M ftO)-b loy
E-MAIL ADDRESS: CQco13 wai-5or 57 ,Navl.coh
OWNER NAME: Caco\ t iak-5' , e e y ,4c -'O(`
CORPORATION NAME (IF APPLICABLE): (P c%S e-5 u n
MANAGER'S NAME: cool vjo. Son TEL.#: 5c &
MAILING ADDRESS: SAnv►Q
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.
1. NSA 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 Departwent.w11 not t
years' records. You must provide new copies and maintain a file at your place of busutesg , ,w
1. 2. IR 1 5 0^s
3. 4.
Ht.
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. e qr o 2. ,5 Q lni Aaki1
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. Caro\ Wo)tso-N, 2. JQ w
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. Caro k 2. J Q4 W
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. N/4 _2.
3. 4.
RESTAURANT SEATING: TOTAL# 2 2—
OFFICE
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 CABIN $55MOTEL $110
_
INN $55 CAMP $55 SWIMMING POOL$110ea.
7LODGE $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
>100 SEATS $200 .ZCOMMON VIC. $60 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 = $ 'MD
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
�' \((.Ct—)C1 L ' Re ci(Pc t
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 IV.
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 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 18, 2020.
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 REWIRE ATEP AN.
DATE: /21P-11
202-/ SIGNATURE: I/V
PRINT NAME &TITLE: CG cV k. W o Son > 4
Rev. 10/15/19
The Commonwealth of Massachusetts
Town of Yarmouth $55.00
Lodging License Fee
Number: BOHL-16-9699-06 Issue Date: 1/1/2022
Mailing Address: Location Address:
JCW ENTERPRISES INC. 308 OLD MAIN ST
CAPTAIN FARRIS HOUSE SOUTH YARMOUTH, MA 02664
308 OLD MAIN STREET
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Lodging House
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Conditions
NUMBER OF ROOMS:
1st floor, 4 bedrooms; 2nd floor, 4 bedrooms;Annex 1st floor, 2 bedrooms.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T.Holway, Clerk
Debra Bruinooge
Health Eric Weston
a ,
Bruce G. Murphy, 'PH, ' :., CHO
Health Director
The Commonwealth of Massachusetts
Town of Yarmouth $185.00
Food Establishment License Fee
Number: BOHF-16-9701-06 Issue Date: 1/1/2022
Mailing Address: Location Address:
JCW ENTERPRISES INC. 308 OLD MAIN ST
CAPTAIN FARRIS HOUSE SOUTH YARMOUTH, MA 02664
308 OLD MAIN STREET
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Food Service; Common Victualler
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Conditions
SEATING: 20
Board Hillard Boskey,M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruc:G. Murphy MP /•.S., CHO
Healt Director
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The Commonwealth of Massachusetts
Department of Industrial Accidents
rIMINOMMIN
I - 1 Office of Investigations
-
=' 1 Congress Street, Suite 100
MINI 41�- ' Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: j CVJ 4 -4-A c_ T?)(} C q t‘ 1
Address: 3O 01 M cx,n S k- .
f4 O
City/State/Zip: cc, yc-Cf\A 0-0 , Phone #: SOS - 7 Lo O -2 1
Are you an employer? Check the appropriate box: Business Type(required):
I.(1 I am a employer with employees (full and/ 5. 0 Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7• ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. 0 Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
4.❑ We are a non-profit organization,staffed by volunteers, 1 LE Health Care
with no employees. [No workers' comp. insurance req.] 12.Q. Other 2je_k 2 6 ,k-cr>, s-}
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: . .-, M ; M J kW:4 1 c , v r c4)c Qs. C o .
Insurer's Address: 5'4 `r11 gid,
City/State/Zip: R:1 t � j\-AF) o i g p 3 - 0(11 -7.0
Policy #or Self-ins. Lic. # 't iC 50o s'..cl X57 So <.0 21 A Expiration Date: 3'1 y)ZO
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the Corm of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: c— Qc l) g-k Date: I -)1 0//20 2-)
Phone#: C - 7 to C - -2- g I S
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5018780-2021A
PRIOR NO. ;WCC-500-5018780-2020A
ITEM
1. The Insured: JCW Enterprises Inc
DBA: The Captain Farris House
Mailing address: 308 Old Main St FEIN:**-***9195
South Yarmouth, MA 02664
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 05/04/2021 to 05/04/2022 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ 1,000,000 policy limit
Bodily Injury by Disease $ 1,000,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals cf Rules,Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 001057635
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $301 Total Estimated Annual Premium $732
GOV I GOV Deposit Premium $746
STATE CLASS
MA 9052 State Assessments/Surcharges
$401.00 x 3.5100% $14
This policy, including all endorsements, is hereby countersigned by 'e.- 04/05/2021
Authorized Signature Date
Service Office: Drawling and 0 Neil Ins Agcy
54 Third Avenue 973 lyannough Road
Burlington MA 01803 Hyannis, MA 02601
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.