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Home My WebLink AboutApplication and WC L3C�6C��MLDD iar�v!/�c,ano,v Cz� � ° ��d�� TOWN OF YARMOUTH BOARD OF H ALTH � � � � t0�4 APPLICATION FOR LICENSE/PERMI -2J�1�5 1 J LO14 * Plea e complete form and attach all necessary docu en r 1 2014. � �o H E A LTH DEPT. Failure to do so will result in the return of yo _z , �� a '� ESTABLISHMENT NAME: � � T D: LOCATIONADDRESS• �IS� Y�'Ia� ,�'�' �1 fI-r„�o✓f-�,� oz6'13TEL.#: .SoB- 7�S-o�IIN MAILING ADDRESS: 9 ^ -F E-MAIL ADDRESS: ly14„ � P� �o �� 1 a c �,o r� OWNER NAME: CORPORATION NAME (IF APPLICABLE):�o I r14�l /C �.A f �n r ��,�o vt � n � �i S 1 nc MANAGER'S NAME: TEL.#: MAILING ADDRESS: �� 53 YYIa .� 5�- (.tle��" U_ c��T1/V1�0�, G 1� POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated - Peol 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 Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all Umes. 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 prov►de new copies and maintain a fiIe 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• PER�GN IN CHA�Ci�— ------ -- - ------ . _ _-- ---- ------- 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 establishxnents 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 Sle 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-chokmg 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 £►le at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L�ENSE REQUIRED FEE PERMIT# B&.B $55 CABIN $55 MOTEL $ll0 S 43�/ INN $55 CAMP $55 'LSWIMMINGPOOL$(l0ea !� , 6606� LODGE $55 _TRAILERPARK $105 �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $]25 —CONTINENTAL $35 NON-PROFIT $30 —>100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 — — —RES[D.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 _VENDING-FOOD $25 CL5,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $�/-��4.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM**•*" ��-'� � �"4�'DO cl�#-ro�az �a��9�� ,ac�oRO� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIVVYY) 03/26/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY 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 REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. � � � � IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy�ies� must be endorsetl. If SUBROGATION IS WAIVED, subjeM to the tertns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holtler in lieu of such endorsement s. PRODUCER CONTACT NAME'. AMITY INS AGENCV INC PHONE FNt 500 VICTORY RD Iac,No,eze: ac,No: MARINA BAV E-MAIL ADDRESS: NORTH pUINCV MA 02171 77W2C INSURER(5)AFFORDING COVERAGE NAIC# iNsuRERn:ACE M RICAN INSURANC PANV INSURED INSURER B'. ° �f�!�� D HOLIDAV VACATION CONDOMINIUMS INSURERC: PO BOX 940 SOUTH VARMOUTH MA 02664 ., iNSURERD: INSURER E: ' INSURER F � �T n 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 AUDL SUBR �LICY EFF POLICY EXP LTR TYPEOFINSURANCE INSR WVD POLICYNUMBER MM/DD/YVVY MMIDDIVYYV LIMI15 GENERALLIA8ILITV EAGHOCCURRENGE $ DAMAGETORENTED COMMERCIALGENERALLIABILITY PREMISES mcurtence $ GLAIMSMFDE �OCCUR MED EXP Nn one erson 8 PERSONAL 4 ADV INJURV E GENERALAGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG POLICV PROJECT LOC 3 UTOMOBILE LIABILITY COMBINED SINGLE LIMIT acdtlen S ANV AUTO A AUTOSULED BO�ILV INJORV Per rsan f ALLOWNED NON-OWNED � BODILYINJURV Para<ciEen E AUTOS q�05 PROPERTYDAMAGE HIREDAUTOS erawitlent E S UMBRELUILIAB OCCUR EACHOCCURRENCE 8 EXCESSLIAB CLAIMS-MADE AGGREGATE E OED REfENTION S WORKERSCOMPENSATION WCSTATU- Ohl- A ANDEMPLOYERS'LIABILITY (6562UB-4494P9O-O-14) 03-02-14 03-02-15 x TORVUMITS ER ANV PROPRIETOR/PARTNER/IXECUTIVE OFFICERIMEA99ER EXCW�ED? V/N EL EACH ACCIDENT ? SOO,OOO (MantlaroryinNH) � Y N�A E.L.DISEASE-EAEMPLOVE 8 SOO,OOO If yes,tlescnbe untlar DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICV LIMIT $ SOO,OOO DESGRIPTION OF OPERATIONS/LOCATIONSIVEHICLES(Attacb AGORD t01,Atltlirional Remarks Sehetlule,lf more spaee is�equiretl) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESGRIBED POLICIES BE GANGELLED BEPORE THE EXPIRATI�N DATE THEREFO,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE TOWN OF VARMOUTH BOARD OF poLItYPRovisioru5. HEALTH nunaoRrzeo iv 1146 ROUTE 28 SOUTH YARMOUTH MA 02664 ��988-2010 ACORD CORPORATION.NI rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD