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HomeMy WebLinkAboutApplication and WC CotANkkl-. 4730SG INtJ TOWN OF YARMOUTH BOARD �OF HEALTH CIEETWIEID ftclik APPLICATION FOR LICENSE/13E t R �� ��` '� �1" * do T cAlot Mfg Dec 1 ;!i ,,t � berAtJ' �`ll4?014 J Please complete form and attach all necessiy�, � .. Failure to do so will result in the return of your application p. cke�EALTH DEPT. ESTABLISHMENT NAME: CatAc& \*003 c2A) N) TAX ID: 0 Zli Sic' LOCATION ADDRESS: x"1'1 �oukie CAWS- I� � Ati* aa�.26' TEL.#: 5'034- 3LD-t1�3 La MAILING ADDRESS: 3Nrne cy �1 �t o v E-MAIL ADDRESS: 4) -Q-opc b�ocVNnv� �Sec ee� ., �M eo OWNER NAME: `t��\ccs\ Nei CORPORATION NAME (IF APPLICABLE): �e..ti.oa Qu' s cu-ykS �'� L . MANAGER'S NAME: VINsPAccAint‘ J. 1`�vZ ) TEL.#: EDS ' 3ba - 434T MAILING ADDRESS: 'AreN e („,„ c,,bo-0-e 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: N�r�9 - YN\a \ covy 2. Pool operators must list a minimum of two employees currently certified in basic water safety, 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 years' records. You must provide new copies and maintain a file at your place of business. 1 . MaNciA IA ResiZOCk 2. A ‘� - ApniciA. 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. rt-1' "-\'` ...1 1 . ..1.- T‘(k r- N ‘ V S\ %1 2. --2volo \fei4 0.0 \(' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1 . °A \ 6 C. 1. V 4 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 . k\f\ i .\ClA wn 3-- R€ uck 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 . Ra.AjU 'f�` C8\yr aRevuicA 2. t.,�•nX,-es-A � Y�,� 3. c,� )evvtc* 3 4. �� ��t�e� �.we.�� J RESTAURANT SEATING: TOTAL # dc:e.3._ OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # _B&B $55 CABIN $55 MOTEL $110 I INN $55 LODGE $55 # ' S�O 1 =CAMP RAILER PARK $$OS WHIRLPOOL 55 1 SWIMMING POOL$ill Oea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # 1 0-100 SEATS $125 4 .(5-.4)2q CONTINENTAL $35 NON-PROFIT $30 >100 SEATS $200 1 COMMON VIC. $60 -fVTS-Z-; _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 = $ 4 GO - OC) *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Utos1 ( ADMINISTRATION • Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth, is now required to hold issuance or renewal of any license permit to operate erate a business if a person or company does not have a Certificate of Worker's . or p er Compensationensation 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 Yarmouth taxes and liens must bepaid prior to renewal or issuance of your permits. PLEASE CHECK Town of APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: purposes For u oses of the limitations of Motel or Hotel use, Transient occupancy shall be and short term occupancy, ordinarily and customarily associated with motel and hotel use. limited to the temporary Transient occupants must have and be able to .demonstrate that they maintain a principal place of residence shall generallyrefer to continuous occupancy of not more than thirty (30) days, and elsewhere. Transient occupancy an aggregate of not more than ninety (90) da s within any six (6) month period. Use of a guest unit as a residence or y dwellingunit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy 11 Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS All swimming, wadingand whirlpools which have been closed for the season must be inspected POOL OPENING: p . prior to opening. Contact the Health Department to schedule the inspection three (3) by the Health Department days pr p g People to opening.. PLEASE NOTE: Peo le 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 S tate certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. CLOSING: Everyoutdoor in ground swimming pool must be drained or covered within seven (7) days of POOL 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: An one who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the Any • � can be required Temporary Food Service Application form 72 hours prior to the catered event. These forms q • p website at www.yarmouth.ma.us under Health Department, obtained at the Health Department, or from the Towns eb y p Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested bya State certified labprior to opening and monthly thereafter, with sample results • Frozen submitted to the Health Department. Failure to do so will result in the suspension or revocation of your 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: January Permits run annuallyfrom 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 B BOARD OF HEALTH PRIOR Q TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A ITE _ A DATE: / // 1 471//i/ SIGNATURE. it PRINT NAME & TITLE: X'C\ Or\ C \ C &I ©l oveA Twateet-eA Rev. 11/03/14 ClientU. 536450 2COLONIALHO \ - - .4-, Ca-11: i:.: CERTIFICLTE OF LIABILITY INSURANCE UA!t (IIRMIDO/YYYY) 4/21/2014 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 13ELOIN. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. 1MPORtANT: 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(s). PHODUCEK CONTACT NAME: Dowling & O'Neil INC. . Eek 508 775-1620 1 Tac.No): 5087781218 Insurance Agency ADDRESS:L 973 lyannaugh Rd., PO Box 1990 a rtii is, MA 02601INSURERIS) AFFORDING COVERAGE NAIL 9 HyINSURER A : Associated Employers Insurance INSURED INSURER a : I Perna Consultants, Inc_ D/B/A Colonial House Inn , INstsiritH C 1 277 Main Route 6A INSURER 0 : INSURER E : Yarmouth Port, MA 02675 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. iNSK SUuH POLICY hi-I- POLICY EXP Li it TYPE OF INSURANCE POLICY NUMBER (MMiuuIYYYY) (MraIUuIYYYY) LIMITS GENERAL LIAWWWti 1 Y t-4(:14 Ot`.t'aiKKFMta- J COMMERCIAL GENERAL LIABILITY DAtfiiQE '� r:ENTEO YKhlvtli's1►i►lF i n:rrutrn.'4 i It) Ativi .MAI l!- T °cCI 1K kri-i 3 t-xt' (Any nne pr rrnn) 1-l-N::'1)NA1 1t Ally !MAW I , GENERAL AGGREGATE A1-N'1 Atic 1*1 A II- t &Ili A'q-q n- rt-K: vw eh n IC.:4'-1st OW-1OP Ata; F*Kt l- I POLICY I-1JFC'r I LOC1 $ . r r Ari 1 OMOHIL6 L1A#3ILi 1 Y CAJMHIPit-1? 1P1111 I- 1 IMI 1 (E =titian') I ANY AUTO BODILY INJURY (Pus Ngtnon) S .mow1 ALL C'WNED ~' rr..,.... - ! At/t t l.�s Ken l u Y Ian IK Y (H rr a:.G�cl::tlt� NON-OWN�If Pl{t3F'I7141Y I?AMAM— rump AUTOS `� At t 1 O iters nt::itfrntl `' A a UMWKtLLA LIAkt OCCUR 1-At:H ot'•taneei Nt'•I- f EXCESS LiAR CLAIMS-MADE AGGREGATE DED _ _ RETENTI=?N S I. 4 a A WORKERS COMPENSATION WMZ80080035742014A V4/01/2014 04/01/20°16 X I I i;K IIM; I p1-H H. AND 1MPLOMKS' LIAUILII Y ANY PHC)PHlf (H,'1 _ I -AHI NI-HA-XI-1:11 f I111.,Y!N E.L. EACH ACCIDENT 654( ,000 FFICERiME .1BER EXCLUDED? iJN N A (Mandalary in NH) I-.t _ IN:41-A:4- .f-A i-nwi t-l�rm-l- $500)}00 If et. datxaib =its . . e► r r1 "5a� �00 I)1- l ON tit- 00-KA 113Net R..l:r E.L. DISEASE -P_UCY LIMIT , v s UtSCKIPI ION OI- OPERAtIONS 1 LOCA I IONS I VEHICLtS(Allarta ACOHu 101 AOdtiton:0 Remarks Srnaouta,If mars spars Is raqutrad) Insurance coverage is limited to the terms, conditions, exclusions, other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered, waived, or eutended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Perna Consultants Inc. DBA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Colonial House Inn ACe6ABANC! WITH THE POLICY PROVISIONS. 277 Main Route 6A • Yarmouthport, MA 02675 AU I HORILtU HEPKESEN I A I!lib pftistravw...Z._ .12" Tr"'Cr in,....qmor#•,—.... .. r• CO: 1988-2010 ACORD CORPORATION. AU rights reserved. ACORD 25 (2010105) 1 of I The ACORD name and logo are registered marks of ACORD S129177/M129406 KKM