Loading...
HomeMy WebLinkAboutApp-License-Certifications .` © 201 4 TOWN OF YARMOUTH BOARD OF HEALTH ;�N 2 Ci 2022 �• '►`\ ` 1 APPLICATION FOR LICENSE/PERMIT -2022 ....i_wli 1p� * Please complete form and attach all necessary documents by D.centhres,Y8H2DH?T. Failure to do so will result in the return of your application .. • - . ESTABLISHMENT NAME: X/,1,s 1/0/141 /fL6/ X ID: - LOCATION ADDRESS: < t i� iltinaI .#: :6-1) . 3 . MAILING ADDRESS: �1� � � �� � .>J` E-MAIL ADDRESS: Pdrri17)_ ie- bttriear Yarid/ z t OWNER NAME: ` CORPORATION NAME (IF APPLICAB E): a • MANAGER'S NAME: / Fp -e( 7 • �' • • 6o.•• _. - MAILING ADDRESS: rel f .)1gc ✓��,pl /Yl .'1 �` ,� D� I POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Oper tor(s) and attach ac py of the certification to this form. I. 1 al cte I t._ 1 dip Etr. , ._. 51 2. JAITIA-4 ilke 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. 1. 2. 3. 4. FOND " i TION MANAGERS - CERTIFICATIONS: Al )o• % ' establishments are required to have at least one full-time employee who is certified as a Food �� P ctiu A ger, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. '; \'a a't.% ies of certification to this application. The Health Department will not use past years'records. I, mus + ide new copies and maintain a file at your establishment. 2 e N. SO HARGE: L., h fo� st blishment must have at least one Person In Charge (PIC)on site during hours of operation. M 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. 1. 2. 4. RESTAURANT SEATING: TOTAL# 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 64SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 >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# <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 = $ 0U-0 *****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 1 7 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 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_thirtv(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 I UIRE A SITEPLAN. / ^ DATE: f• ! SIGNATURE: ! ' PRINT NAME& TITLE: 6�',Q� L• h7 kaiaoe Rev. 10/15/19m;n 1// 1/ The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1294-07 Issue Date: 1/1/2022 Mailing Address: Location Address: KING'S WAY TRUST 64 KINGS CIRCUIT 64 KING'S CIRCUIT YARMOUTH, MA 02675 YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE 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 OUTDOOR SWIMMING POOL Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway,Clerk Debra Bruinooge Health Eric Weston Bruce G. Mu ,hy, •H,R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-15-1293-07 Issue Date: 1/1/2022 Mailing Address: Location Address: KING'S WAY TRUST 64 KINGS CIRCUIT 64 KING'S CIRCUIT YARMOUTH, MA 02675 YARMOUTHPORT, MA 02675 IS HEREBY GRANTED A 2022 LICENSE 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 OUTDOOR SWIMMING POOL Board Hillard Boskey, M.D., Chairman Mary Craig, Vice Chairman Of Charles T.Holway,Clerk Debra Bruinooge Health Eric Weston Bruce G. Murphy, M' , R.S., CHO Health Director DATE(MM/DD/YYYY) ACORO® CERTIFICATE OF LIABILITY INSURANCE 12/16/2021 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 CONTACT NAME: RogersGray, Inc. -Kingston Branch PHONE - FAX 63 Smith Lane (A/C.No.EA):508-746-3311 (A/C,No):877-816-2156 E4AAIL Kingston MA 02364 ADDRESS: mail@rogersgray.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Philadelphia Indemnity Insurance Company _ 18058 INSURED KINGWAY-01 INSURER B:Greenwich Insurance Com any 122322 Kings Way Condominium Trust rr 702 64 Kings Circuit INSURER C: JAN +1 0 + Yarmouthport MA 02675 INSURER D: INSURERE: -{EPT TH INSURER F: COVERAGES CERTIFICATE NUMBER:466079874 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP WLIMITS LTRINSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY PHPK2357435 12/15/2021 1/1/2023 EACH OCCURRENCE _ $1,000,000DAMAGE RENTED CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO X POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) l$ OWNED SCHEDULED BODILY INJURY(Per accident) $ __AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) B X UMBRELLA LIAB X OCCUR PPP7464842 12/15/2021 1/1/2023 EACH OCCURRENCE $25,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $25,000,000 DED X RETENTION$n $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Commercial Property PHPK2357435 12/15/2021 1/1/2023 Blanket 166,000,000 Commercial Property Deductible 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 129 Building,456 Unit Condominium Association Special Form subject to exclusions;Replacement Cost; 100%Coinsurance;Agreed Value applies. Standard Separation of Insureds condition applies. Property is subject to 2%Windstorm/Hail deductible(min$100,000)and$25,000 Per Unit Water Damage deductible Employee Theft:$2,000,000-Effective 12/15/2021-1/1/2023-Travelers Casualty and Surety Company of America-property management company is included. Ordinance or Law:Coverage A-Included;Coverage B&C-$300,000 Combined Each Building Flood-$2,500,000 Limit,$100,000 Deductible-Flood exclusion applies to locations in the Flood Zone A,A1-30,AE,AH,AO,A99,AR,AR/AE,AR/AH,AR/AO, See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Barkan Management 64 Kings Circuit AU ED REPRESENTATIVE Yarmouthport MA 02675 ounce)/ "7„, 4,..„ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD