The URL can be used to link to this page

Home My WebLink AboutApplication and WC . . o�-�,N�s+—._ b TOWN OF YARMOUTH BOARD OF HE T� ��: � - -- ` � � APPLICATION FOR LICENSE/P 1 .:�2�°,`y: � . �"� s ,�+,�'� L �F 2015 �"°' * Please complete form and attach all necess cu ' er 5 2014. Failure to do so will result in the return our t n pa�ket. - - - ---r ! ESTABLISHMENT NAME: T ID: �! LOCATION ADDRESS: TEL.#: 50 9 2 MAILINGADDRESS:2 �S�nn o � >« � a h1.-o ✓L 1'L1 Y�7StL12 E-MAIL ADDRESS: �d��ro�v,rAC� �p�;,,��r��,2�,rn��.(„�yv� OWNERNAME: C7co.i -��,�4, [ CORPORATION NAME (IF APPLICABLE): MANAGER'S NAME: TEL. : 2 0 MAILING ADDRESS: r 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--- - — -- - 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 Sle at your place of business. 1. 2• 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one fixll-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. l. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation. 1. 2• ALLERGEN CERTIFICATIONS: All food service establishments aze required to haue 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 a11 times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Deparhnent 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 PERM[T# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE RMIT# B&B $55 CABIN $55 I MOTEL $I10 � -b -1NN $55 CAMP $55 2 SWIMMING POOL$1 t0ea -0 �O7S LODGE $55 _1RAILERPARK $I05 �WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# � 0-100 SEATS $l25 _CONTINENTAL $35 NON-PROFIT $30 >700 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $SO RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VEND[NG-FOOD $25 <25,OOOsq.ft. $i50 _FROZENDESSERT $40 _TOBACCO $110 NnMEcxnrrcE: $�s AMOUNTDUE _ $ �}�O.00 *"***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 � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth ta�ces 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 oFMotel or Hotel use,Transient occupancy sha11 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 thirly(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 wllection 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 azea 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 SEA50NAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Deparhnent 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 forxns 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 CA�`ES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: 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 RESPON5IBILITY 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.), NNST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SIT AN. DATE: `7� /7 � SIGNATURE: ', PR1NT NAME&TITLE: � d � , � Rev. 11/03/14 �I � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations I Congress Street, Suite I DO Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Auulicant Information Please Print Leeiblv Business/Organization Name: �oa.,n ��'� �PGTc C Vl i t� � �1� Address: � �- S, S��P �\��. City/State/Zip: Kl Phone #: SO�S 3�`6 2�3 3 Are you an employer? Check the appropriate box: Business Type(required): 1.[�I am a employer with�_employees(full and/ 5. ❑ Retail or part-time).* 6. ❑ RestauranllBaz/Eating Establishment �.0 Tam a sole propnetor oi partnership and have no 7, � Office and/or Sales(incl.real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We ue a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.0 Health Caze 4.❑ We are a non-profit organizarion,staffed by volunteers, � with no employees. [No workers' comp. insurance req.] 12.[�-Other •My applicant that cttecks box#1 must also fill out the section below showuig their workers'compensalion policy infoimation. *•If ihe cocporate officers have exempted themselves,but the coiporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is providing workers'compensa�,tion\insurance for my employees. Below is the policy informatioa Insurance Company Name: ��(`� \�l b��'�(l �Y�t.p �l�S�L. Insurer's Address: � �--��n � �1 C' �s� � , City/State/Zip: -�"�� d_.�_�YV1 c�� L �n� �' �n Policy#or Self-ins.Lic. # l ��_ � ��—� ��SS 00 C� Expiration Date: + � I I � I �� Attach a copy of the workers' compensafion policy declaration page(showing the policy nnmber and espirafion date). Failure to secure covera�e as required under Section 25A of MGL c. 152 can lead to the im�osiuon of criminal penalries of a _ _- -- --- _ __ _ _— — - -- fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance covemge verification. I do hereby certify,under the pains and penalHes ofperjury that the information provided above is true and correct. Si�nature:�\ �2 C1QA r'S\1 n n 1 Date: �� Z�1 � Phone#: �— C Officia!use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Liceasing Board 5. Selectmeds Office 6. Other Contact Person: Phone#: www.mass.gov/dia 1 '`�� CERTIFICATE OF LIABILITY INSURANCE DFTE�MMIDDIYYYY� 2/3/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. TNIS CERTIFICATE DOES NOT AFFIRMA7IVELY OR NEGA7IVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES � BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER(3�, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the eertfflwte holder is an ADDITONAL INSURED,the polfey(les) must be endorsetl. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,eertain policies may require an endorsement. A sfatement on this ceRificate does not confer rights to the ceRificate holtler in Ileu of such endorsement s. � PRODUCER CONTACT FRAN SEGUR GENATT V LLC PHONE .516-869-8666 F'� . 516-465-7279 � 3333 NEW HYDE PARK RD SUITE400. E'"'^'� .FRANS@GENATT.COM NEW HYDE PARK NY 11042 INSURER S AFFORDINGCOVERAGE NNICO � �Nsua�aa:Zu�ich North AmOrica insuneo NEWPHOTE INSURERB: Newport Hotel Group LLC, Etal INSURERC: 28 Jacome Way Middletown RI 02842 INSURERO: '. iNsursers e: � INSURER F: COVERA ES CE FICATE N BER: 1690612351 REVISION NUMBER: THIS IS TO CERTIFY THAT 7HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED. NOPMTHSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W1TH 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 AN�CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCE�BY PAID CLAIMS. INSR �Tµ TYPEOFINSURANCE POLiCYNUMBER MhVDICYEFF MR�VUD EXP 11M1T5 COMMERCIALGENERALLIqBIUTY EACHOCCURRENCE E CLAIMS-MA�E �OCCUR AMAGE TO RE TED PREMI Eaowurrenca 5 MED EXP Arc/one pe�san) § PERSONALSADVINJURY E GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE 5 POUCY❑�E�T �LOC PRODUCTS-COMP/OPAGG S OTHEft' E AUTOMOBILE LIABILITY Eeaccitlan� E ANVAUTO BODILYINJURY(Perpareon) S ALL NMED SCHEDULED AUT 5 AUTOS BODILYINJURY(PeracdtlanQ S HIREDAUTOS q�Npg�E� PROPERTYDAMAGE � Per actitlant S UMBRELLALIFB ppCUR EACHOCCURRENCE 5 EXCESSLWB ClAIMS-MADE AGGREGATE E OED RETENTIONS $ q WORKERSCOMPENSATION WC014006600 1/15/2014 11/15/2015 q ANOEMPLOYERS'WBRATY YIN WC014008000 it/15/2014 11/15/2015 STAT E ERH ANYPROPRIETOfl/PARTNEWEXECUTIVE E.LEACHACQDENT 57,000,000 OFFICERflAEMBEREXCLUDED'! � N�A (MandaroryinNX) E.L.DISEASE-EAEMPLOVE E1,000,000 I(yea,tlesaibe untler DESCRIPTIONOFOPERATIONSOabw E.L.DISEASE-POLICYLIMIT f1,000,000 DESCRIPTION OF OPERATION5/LOCN110NS I VEHICLES �ACORD f01,AtltlWonal Ramarks Schetlule,may be akacMtl M mon spaca is mqulrvE� As respects Harborview Hotel Investors, LLC,213 Ocean Street, Hyannis, MA 02601 and Ocean Mist LLC, 97&73 South Shore Drive, South Yarmouth, MA 02664 CERTIFICATE HOLDER CANCELLATION 3 SHOULD ANY OF THE ABOVE DE3CRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town of Yarmouth Board of Health ACCORDANCE WITH THE POLICY PROVISIONS. 1146 Route 28 South Yarmouth, MA 02664 � nu�/xo7naeoreEraeseNTnnve / ��)- ' Y OO 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/O7) 7he ACORD name and logo are registered marks of ACORD