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HomeMy WebLinkAboutApp-Permit-Compliance TOWN OF YARMOUTH BOARD OF HEALTH t• �\ ` 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: Ski fp.. . CH0r40: 1bbJv 6 TAX ID: LOCATION ADDRESS: /3".9._ S',00:71‘ r110 r� af TEL.#:sag 3 9c/ -79-6 MAILING ADDRESS:SA ) )C\. )9y,9od L r)1 4 O26¢- E-MAIL ADDRESS: s/.1•L ip _ 7 1 � e- •X002 P OWNER NAME: c-AIJ '9' L/ V CORPORATION NAME (IF APPLICABLE): Se r, Li/6'c.c) , AIL MANAGER'S NAME: Ami/ Da.A.)6y TEL.#:7�it 83 6 s-2-7 Z MAILING ADDRESS: 19 Co/✓GUJ6.A) Oil Soy ,/-'2'-/xk4 i4,4 r2.6,<4- POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law d'lease L's ,t1 designated Pool Operator(s) and attach a copy of the certification to this form. L.,,Li IC I. 2. APR 0 7 2022 Pool operators must list a minimum of two employees currently certified in standar h�qqt cc ,Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at a lfliimmet'.`'PPease 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. I. 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. I. AL-AtA --D '',/---4-A/6)./ 2. 4 1 4 Ai ,--- 4, ,,te— PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 4 9...,...,34,„,......)„. 2. , -iNi - ,�� 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,afifile at your establishment. I I. A I�/ DK-- t9 2. 4p,4I � -1 S�=%' 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. I. 4 /3' 1J./ 2. y �✓T1..-,,7/ /. 3. 14tP4-) . ¢✓ 4. __ RESTAURANT SEATING: TOTAL # I. / OFFICE USE ONLY LODGING: LICENSE REQUIRED NEI: PERMIT 4 LICBNSL REQUIRED FEE PERMIT# LICENSE REQUIRED FEB PERMIT 4 B&B $55 _CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$I IOea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. FOOL)SERVICE: LICENSE REQUIRED NEI: PERMIT 4 LICENSE REQUIRED FBI; PERMIT 4 LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 t>100 SEATS $200 $ COMMON VIC. $60 WHOLESALE $80 —RESID. KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT 4 LICENSE REQUIRED FEE PERMIT#- LICENSE REQUIRED FEE PERMIT 14 <50 sq.11. $50 >25,000 sq.11. $285 VENDING-FOOD $25 _<25,000sq.Ii. $150 FROZEN DESSERT $40 'TOBACCO $110 e)"" *****PLEASE NAME CHANCE: $15 AMOUNT DUE = $ 3 *****PLEASE TURN OVER AND COMPLETE D'I'VER 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 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 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 COMME CE ENT. RENOVATIONS MAY REQUI E A SITE PLAN. DATE: � SIGNATURE: PRINT NAME & Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $300.00 Food Establishment License Number: BOHF-15-1916-08 Issue Date: 1/1/2022 Mailing Address: Location Address: BEACHVIEW INC. 152 SOUTH SHORE DR THE SKIPPER RESTAURANT SOUTH YARMOUTH. MA 02664 152 SOUTH SHORE DRIVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Food Service; Frozen Dessert Manfucturer; 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 *TOTAL SEATING - 144: Inside- 100; Upper Outside Deck- 44 *FROZEN DESSERT: Regulation 105 CMR 561.009 requires monthly plate count and coliform tests. Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston n 1 r' Bruce G. Murp MP , R.S., CHO Health Director The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 v..1 — Boston,MA 02114-2017 •-• www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑ 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. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box#1 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: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 form 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: Date: Phone#: 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 i , ill l • • nsc NSC CPR Course National Safety Council " Adult:Child, Infant, FBAO iE Name: Alan Delaney _- Security Control No. 1Address: Skipper Restaurant - q 3 R q- Address: 152 South Shore Drive City, State, Zip: South Yarmouth,MA 02664 _ u Course Completion Date: 04/02/2022 Training Center: Cape Cod Safety Training Expiration Date: 04102/2024 Instructor Larne: Rick_Todd ti instructor ictor NV rntDer 1040918 _ Q C Al i Alan Delaney - has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. Fi The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of c I preventable injuries and deaths so people can live their fullest lives,We create a culture of safety to not only make people safer at B work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining THIS DOCUMENT IS VOID IF REPRODUCED •••nsc sect;rity Control No. ae.e,e . i I nsc Alan Delaney National Safety Council has completed the - We want your feedback! Mac CPR Course Adult,Child,infant FBAO&AED Training Center: Caps Cod Safety Training Please visit nsc.org/firstaidevaluation to completion : 04l0?f2022 take a brief survey and share your opinions Expires:. 04192f2024 Instructional Hours: about the NSC course you completed. / . �a ,g #1040318 instructor Signature Instructor No. • :! Keep this card for your records.Void if reproduced. 50M11092021 07070 National Safety Council /91/4-0000 a .. nsc NSC CPQ Course National Safety Council Adult-Child Child, Infant, F AE- - v Name: Aidan Delaney Security Control No. Address: Skipper Restaurant _ CI q r 7 Address: 152 South Shore Drive City, State,Zip: South Yarmouth,MA 02664 Course Completion Date: 04102/2022 Training Center: Cape Cod Safety Training Expiration Date: 0410212024 Instructor Name: Rick'odd Instructor N im e : 1040 18 Aidan Delaney has successfully completed the NSC CPR Course basedon the current Guidelines for CPR and ECC. _ ___ _ I The National Safety Council is America's leading nonprofit safety advocate.We focus on eliminating the leading causes of it 1 preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining i- 4- ,---- THIS THIS DOCUMENT IS VOID IF REPRODUCED ':nsC - Security Control No. ewanrWNW Coma .A / . -.nSC Aidan Delaney _ / National Safety Council i ---- - - i has completed the We want your feedback! NSC CPR Course Adult,Child,infant FBAO a AED Training Center: Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion Data:_` 0410 - Exp take a brief survey and share your opinions " instructional Hours: about the NSC course you completed.. / ,-.K #1040918 Instructor Signature Instructor No. \\-.... ) Keep this card for your records.Void if reproduced. 50M11092021 52020 National Safety Council 70174-0000 L d . gli 1. nsc NSC CPR Course National Safety Council Adult, it infant N li Name: Amy Delaneyii Security Control No. Address: Skipper Restaurant Address: 152 South Shore Drive City, State, Zip: South Yarmouth,MA 02664 - P Course Completion Date: 04/0212022 Training Center: Cape Cod Safety Training Expiration Date: 04102/2024 Instructor-Name', Rick Todd instructor Number: = 1040910 -- Amy Delaney has successfully completed the NSC CPR Course based on the current Guidelines for CPR and ECC. il The National Safety Council is America's leadin non rofit safe ... 9 p ty advo;:ate.We focus on eliminating the leading causes of 9 t preventable injuries and deaths so people can live their fullest lives.We create a culture of safety to not only make people safer at iI I I work but also to make people safer beyond the workplace.For more life-saving courses from NSC please visit nsc.org/fatraining g 1 - THIS DOCUMENT IS VOID IF REPRODUCED ■nsc Security Control No. r e . xeuar s.mycam� ■ i ns Amy National Safety Council AiYty Delaney g - ` has completed th9 We want your feedback! Nsc CPR Course ,dolt,Chik9,Infant FIBAO&AED Training Cerner. Cape Cod Safety Training Please visit nsc.org/firstaidevaluation to Completion lie:-_= - mann _ take a brief survey and share your opinions Expres... 0420E4 - instructional Hours: about the NSC course you completed. ( r"' >,� #1040918 Instructor Signature Instructor No. - _ Keep this card for your records.Void if reproduced. 50M11002021 e2020 National Safety Council - - _ /9174-0000 Workers Compensation and Employers Liability Insurance Policy Insurer ID No(s): 34355 MA Retail Merchants WC Group Inc. —-- PO Box 859222-9222 Carrier Policy#: Policy Period Braintree, MA 02185-0000 014005032678122 01/01/2022 to 01/01/2023 Information Page Renewal Policy FEIN: 043438184 Item 1: Named Insured and Address Carrier Prior Policy#: 014005032678121 — -- Beachview, Inc. ---- Agency The Skipper Restaurant Deland Gibson Insurance Associates Inc. 152 South Shore Drive 36 Washington St South Yarmouth, MA 02664 Wellesley Hills, MA 02481 Other Workplaces Not Shown Above: No Other Workplaces for this Policy Additional Named Insured: See Additional Named Insureds if Applicable Type of Business: Corporation Federal ID#: 043438184 Risk ID: 000000000 NCCI I Bureau#: 34355 Unemployment ID#: File#: 014005032678122 Item 2. Policy Period The policy period is from 12:01 AM on 01/01/2022 to 12:01AM on 01/01/2023 based on the insured's mailing address time zone. Item 3.Coverage: A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000.00 each accident Bodily Injury by Disease $ 500,000.00 policy limit Bodily Injury by Disease $500,000.00 each employee C. Other States Insurance: D. This policy includes these endorsements and schedules: WC000000C(01/15), WC000414A(01/19), WC000422C(01/21), NOE(01/01),WC200102(01/14), WC200301(04/84), WC200302A(09/08), WC200303D(08/10), WC200306B(06/13),WC200405(06/01),WC200601A(07/08) Item 4: Premium The Premium for the policy will be determined by our Manual of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code# PremiJm Basis Rate Per$100 of Estimated Annual Premium Total Estimated Remuneration Annual Remuneration See Schedule of Operations on Following Page(s) Minimum Premium Prorated Premium Estimated Annual Premium Expense Constant Deposit $261.00 $6,531.00 $6,531.00 Issuing Office: 35 Braintree Hill Office Park Ste 206 Date Printed: $0.00 $0.00 Braintree MA 02185-0000 01-13-21)22 Countersigned by: Form#WC 00 00 01 C (Ed. ) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved. Page 1 of 1 .0 Eh,' may... ;''';'•;- _ -+.h ¢ _ - ,, ,'' hi . ,." Ott r.�- ' y� - 27 r '� --... , -- 1, 1 ;. .- jaiyy it '''''nr 1i s T,JG C {sswss-aa<Sa s yo o.op�!�%sc_�+sa .. C ��_� -epi—�'cT�:� !$ 9 __ ft ,$7 »73q ti. 4a - .moi i_ Asa : - 6_ ,.., .., ,.66.4„ O - 4 {, ‘:"`›.- '4;1 :::. -:.?" ''''''.* 1 . r) ,, ,,,., i., -G) ,.., ,... , ,.., z.....• �, Fi! 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