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HomeMy WebLinkAbout2022 App-License-Certifications ��► TOWN OF YARMOUTH BOARD OF HEALTH `,A`N1 8 ZOZZ �\ '` APPLICATION FOR LICENSE/PERMIT - 2022 * Please complete form and attach all necessary documents by Dei, ' +'b:T aid ' PT. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Sup CcomVcil cs+k -3 e- Oce.r\ TAX ID: LOCATION ADDRESS: O 5 ,S\nore r• 5- 1 a f M ov,kk TEL.#: 50$ 3q $ (49-az MAILING ADDRESS: t ,• t r� E-MAIL ADDRESS: ,jv s row Q. Nb MAIL . c. or, OWNER NAME: K Z rr 4-N G-0L, CORPORATION NAME(IF APPLICABLE): Su r c Ca nb.e.r _n c . MANAGER'S NAME: 3%4:4, £ ,N3.2\ TEL.#: 50S Q31- 58 1 MAILING ADDRESS: _1-011- 5. Strlarc. S . A(ZM a�Et•I 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. Z-us\--* 2n,s 0\ri 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 yearsrecords. You must provide new copies and maintain a file at your place of business. 0v.K 2. Mho\A To c Ro'A 3. v,s5eL-- Si CAA Cr- 4. 81W-3ntz-Pt M (,t 9.12. 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. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT 4 _B&B $55 CABIN $55 MOTEL $110 INN $55 CAMP $55 SWIMMING POOL$110ea. LODGE $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 COMMON 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 = $ 12_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 X 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: YES4\_ 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 PROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ E A S LAN. DATE: 1 5 as SIGNATURE: PRINT NAME& TITLE: J u s\-.4. Ti‘S()la M Rev. 10/15/19 The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Lodging License 4141 Number: BOHL-16-10888-06 Issue Date: 1/1/2022 Mailing Address: Location Address: SURFCOMBER INC. 107 SOUTH SHORE DR SURFCOMBER ON THE OCEAN SOUTH YARMOUTH, MA 02664 107 SOUTH SHORE DRIVE SOUTH YARMOUTH, MA 02664 IS HEREBY GRANTED A 2022 LICENSE TO OPERATE: Motel 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 MOTEL ROOMS-33 Board Hillard Boskey, M.D.,Chairman Mary Craig, Vice Chairman of Charles T. Holway, Clerk Debra Bruinooge Health Eric Weston 4 Bruce G. M i rphy, MPH,R.S., CHO Health Director The Commonwealth of Massachusetts Fee Town of Yarmouth $110.00 Swimming Pool Operations License Number: BOHSP-16-10891-06 Issue Date: 1/1/2022 Mailing Address: Location Address: SURFCOMBER INC. 107 SOUTH SHORE DR SURFCOMBER ON THE OCEAN SOUTH YARMOUTH, MA 02664 107 SOUTH SHORE DRIVE SOUTH YARMOUTH, MA 02664 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 Weston41111 4 Bruce G. Murph I MP , •.S., CHO Health Director �.....N SURFINC-02 SANDERSON3 ACORCP DATE(MM/OD/YYYY) kir./ CERTIFICATE OF LIABILITY INSURANCE 11/23/2021 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 License#1780862 CONTACT NAME: HUB International New England PHONE 978 657-5100 FAX 978 988-0038 300 Ballardvale Street (ac,NLo,Ext):( ) (A/c,No):( ) Wilmington,MA 01887 _,=- AD�RIESS: L v INSURERS)AFFORDING COVERAGE NAIC# INSURERA:AIM, Inc. INSURED INSURER B: Surfcomber Inc HEALTH DEPT. INSURER C: 107 South Shore Dr INSURER D: South Yarmouth,MA 02664 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. INSR TYPE OF INSURANCE ADDL SUBR WPOLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYY) (MMIDDIYYYYI COMMERCIAL GENERAL LIABIUTY _EACH OCCURRENCE $ — CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence.) $ MED EXP(Any one person) $ -PERSONAL&ADV INJURY $ - GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ ACOMBINED SINGLE LIMIT AU LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED — SCHEDULED AUR _ AUTTOS ONLY _ AUTOSNBODILY INJURY(Per accident) $ AUTOS ONLY OS ONLYY (Per accidentDAMAGE $ $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X I STATUTE PER I I ETH AND EMPLOYERS'LIABILITY WCC-500-5017560-2021A 1/1/2021 1/1/2022 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YNN N/A E.L.EACH ACCIDENT $ OFFICER/MEMBEER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ?s9----?,h";-9— I ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r . `�L:. +�.�y� -� s �� ? *1144 e v- `;' may, "- s .Y ��-♦ F.i • x`6. �'.t - ":11::_:-::';',7"-• „_- 11 *k.'' i'L`t `rt .iit� ` :*X1 x'jyw 1 ,+ z?-;- i`7'., r3 yc'4 : to * -f''',:'A '�J`'; ' � w`s2` j.�^,t x rt - ♦t. f7 t ♦ t__ I♦ F, 7- fSb .5-1-tri.; . v - _ r �1Fd ,g` a A -. _ 7 i ' l'%,'z r te r`'� It! ! 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U ° w m UU 0 tl) - .� U m • CD CU (13CU 0 8 ai 3 = 0 U J - Cl) = U CO _ } TS d $ Q cao r 8 a, > 0 1-- vi 3 ,.per 4? 1 L` JAN 1 8 2022 HEALTH DEPT. BASIC LIFE SUPPORT BASIC LIFE SUPPORT BLAS Training Sylvester Consultants,Inc. Provider _ American Center Name Heart Association. Training MA20132 Melissa Leman Center ID has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association IC City,State Hyannis,MA Basic Life Support(GPfi and AED)Program. TC Phone (508)771-8700 Issue Date Renew By eCard Code �"'__j'g7 Instructor { 'i-.Z.":> ; Name Gerald Tierney 9/23/2020 09/2022 205505834726 •t:4, .„ Instructor ID 11060217412 To view or verify authenticity,students and employers should scan this 5.*- erii o OR code with their mobile device or go to www.heart.org/cpr/mycaids. Q2020 American Heart Assocanon 15-3001 R3g0 Directions 1. Cut along dotted lines 2. Fold both halves together 3. Use adhesive to combine halves Certificate of Completion American Red Cross E.----,-,5..-- .;V Training Services JAN 1 u 2022 Maria Todorovarzi • • HEALTH DEPT has completed the requirements for . 1 LEI Adult and Pediatric First Aid/CPR/AED W, �'S} 1 conducted by 1 .7'�ri � American Red Cross ..4 1 .it Date Completed:4/17/21 J 4 Validity Period:2 Years •1•41L. � Certificate ID:00JIH23 " '