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Home My WebLink AboutApplication and WC r TOWN OF YARMOUTH BOARD OF HEALTH AP PLICATION FOR LICENSE/P t! IT - zoi " i _- ALU 1) 8 2014 . ittiggetQu O g-5 i ,..11,6M- r 1 77' r 2 t r * Please complete form and attach all necessa 4 of Bents y Dec. mi1f'T. Failure to do so will result in the rets of -applcationpxck _ ESTABLISHMENT NAME: Ola 3s Ri v6a. Li 4 z- TAX ID: LOCATION ADDRESS: 9 3 J (4-E 2 8 S a fi YA/7-04c. a �.-1, IA TEL.#: 540 8 ''Mb -- q91 MAILING ADDRESS: S # r E-MAIL ADDRESS: s3 ; cs'L. L;8v A-S CP CO \ c44-4- . ii)(54-- OWNER NAME: ' •R 41,m.oetfro a- , JAr) TION NAME (IF APPLICABLE :8 Ass • ; � r - b r s C.c '+ L �� oA$ ;maCORPORA APPLICABLE) 76 NAME: la if fn O D G. . I.--A u -z TEL.#: 5D 8 - '1 (0o - -`q9 47 MAILING ADDRESS: - AN 6 POOL CERTIFICATIONS: The ool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated p Pool Operator(s) and attach a copy of the certification to this form. _ _ �__ _ 1 . 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and CommunityCardiopulmonary 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 past not use years' records. You must provide new copies and maintain a file at your place of business. 1 . 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. 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 thep remises at all times. Please list your employees trained in anti-choking procedures below and attach employee copies of ee certifications to this form. The Health Department will not use past years' records. p p y 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 # 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 # 1 <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING - FOOD $25 <25,000 sq.ft. $150 FROZEN DESSERT $40 1 TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ 1 (0 O .O O ge, d let cm-, oo *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ciut 3ZJS /2/69/4 • : r ADMINISTRATION = S 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 and liens must bepaid prior to renewal or issuance of your permits. PLEASE CHECK Town of Yarmouth taxes APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS T1ANSIENT OCCUPANCY: For purposes es of the limitationsof 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 shallgenerally refer to continuous occupancy of not more than thirty (30) days, and p Y • days within anysix (6) month eriod. Use of a uest unit as a residence or ore than ninet 90 p gan aggregate of not m y ( ) • Room Occupancy Occupancythat is subject to the collectionofp y not be considered transient. � dwelling unit shall Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS must be inspected wadingand whirlpools which have been closed for the season p OPENING: All swimming, POOL . bythe Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) p sit in thepool area until the pool has been days prior to opening. PLEASE NOTE: People are NOT allowed to 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 7 2 hoursprior 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 or revocation of your Frozen Failure to do so will result in the suspension submitted to the Health Department. 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. 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 15, 2014. 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 MA 'i • IRE A SITE PLAN. DATE: 12 - 1 SIGNATURE - PRINT NAME & TITLE: RA1/10.v044-,3) G. - (g'in • Rev. 11/03/14 Dec, 3. 2014 2 : 13PM Brigar Express Stns 518 -438 -0224 No . 4197 P. 1 / 1 a DATE(MM/001 YYY) ACG RD . CERTIFICATE OF LIABILITY INSURANCE 12!03/201 a 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 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. PRODUCER CONTACT NAME Cove Risk Services. LLC PHONE FAX 1B[S�atD- EXtt: [A/C, Nal: PO Box 859222-9222 E-MAIL Braintree, MA 02185 ADDRESS: -- IN•SURER(SlaFFOR0INO COVERAOE _._ NAIL X _ INSURERA: MA Retail Merchants WC Group Inc. INSURED INSURER 0 : Bass River Di5Cpunt Liquors, Inc. INSURER C: — 931 Rte. 26 South Yarmouth.. MA 02864 INSURER D: tiR� INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER; 08503 REVISION NUMBER: 00001 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW I-LIVE 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 POLImS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IHR ADD a tibJ'EFF POLICY EXP LTR TYPE OF INSURANCE ASR . 8L, POLICY NUMBER JM[m,tYYY jMj.vDo'YYYY_ 11411T5 GENERAL LIABILITY EACH OC.CURREtCE S COMMERCJA1 GENERAL LIABILITY PREMISES CLAIMS-MADE I I OCCUR MED OtP Oild PCMOI c PERSONA.a ADV IUJURY S GENERAL AGOREOATE g t N.IY w r OEM L A00REO,TE LIMIT APPLIES PER: PRODUCTS- C,OMPIOP AGO S POLICY PRO, ['1 LOC S JECr AUTOMOBILE LIABILITY COMBINED SINGLE1JMIT (Ea accide n0 ANY ALff) BODILY INJURY(Per oer cr* S ALL OIM ED SCHEDULED BODILY INJURY(Per aocICsnl) S AU?O3 AUTOS PROPERTY DAMAGE S HIRED AUTOS AUTOS (Per bvcidE+n[),. UMBRELLA LIAR �- OCCIA EACH OCCURRENCE S EXCE35 LIA13 CLAIMS-MADE AGGREGATE S REEN 5 WORKERS COMPENSATION ,..�.... a ,�,... x STATU, OT 1- TORY LIMIT.3 _ • AND EMPLOYERS' LIABILITY Y/N �� J ANY PROPRiErORIPARTNERIEXECuT&VEN t A E.L. E&cH f CCIDENT 5 100,000 OFFICER/MEMBER EXCLUDED? (Mendaloty IA NH1 014000501077115 1(0112015 1101/2016 E.L. DISEASE- EA EMPLOYE; S 100.000 I i Ie., oed,be under OcSCRIPTION OF OPERATIONS below I I E.L. DISEASE - POLICY LIMIT S 500,000 A DESCRIPTION OF OPERATIONS/LOCATIONS tVEHICLES (At[rlchACORO 101.AMIIIonaI Remarks 8cheeule, if more Vara Is required) Fax 50B-398-0838 508-760-3472 508-760-5904 CERTIFICATE HOLDER CANCELLATION Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1146 Rt. 28 THE EXPIRATION bATE THEREOF, NOTICE WILL BE DELIVERED IN South Y8rrnuuth, MA 0204 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRE&ENTAYIVV 01988-2010 ACORD CORPORATION. All rights reserved. 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