HomeMy WebLinkAboutApplication and WC GiG�GUMGD
TOWN OF YARMOUTH BOARD OF HEALTH �
APPLICATION FOR LICENSE/PERNIIT-26}�t���� MAY 0 8 2015
'Please complete form and attach all necessary dceuments by December 13 20 3.
Failure to do so wili result in the retum of your applicatwn pac et. HEALTH DEPT.
ESTABLISHMENT NAME: ' r p}{ID� _ �5l�
LOCA7ION ADDRESS: 8� r i n,G J G/Lti.�.� T HAM..�nr-p2� TEL#� Z1¢ d10 t�7 G
MAILING ADDRESS:
E-MAILADDRESS: ce/'vi / O �'�IL��C �' 4� M � L � � R
owrrExtvntv�: K�6, uay T�kar �' �a f�i i� ��'
CORPORATION NAME(IF APPLICABLE): KiNGS ww� SA,LuT lnrC
MANAGER'SNAME:l�.�,I2it ot. vLf� � TEL#' ')Srb)�j' 77/i
MAILING ADDRESS: �t lc�iJLd �i 2 iT �/�2n_o�..oN ggqT
POOL CER1'IFICAT[ONS:
The pool sapervisor must be cerlified as a Pool Operator,as reqaired by State law. Please List the designated
Pool Operator(s)and�attach a copy of the certification to[lils form.
1. 2.
Pool operators must list a minimum of two emplo ees currently certified in basic water safeTy,s[andard 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 uew copies and maiutain a file at yoor place of basiness.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS-CER'IZFICATIONS:
All food service establishments aze required to have at least one full-time employee who is certified as a Food
Protection Maziager,as deSned in the State Sanitary Code for Food Service Establishmen[s, 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 fde at your estabfishmeot.
1CM2�sT+AH�2 OLrv£R! /0324�4l 2.
PERSON IN CfIARGE:
Fach food establishment must have at least one Person In Chazge(PIC)on site during hours of operation.
1.G/J/1�r S T�f A I{aS`t O L iglLt 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)(3xa). Please attach
copies of ceRification to this application. The Health Departmeot will not use past years'records. You must
provide new copies and maiutaie a file at your establishment.
. 1ClLe,t�elstierLOi ..r�t`L..r ,(,�(��,`� 2.
HEIMI,ICH CER'I'IFICATIONS:
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 Deparhnent will not use past years'records.
Yoo must provide new copies aud maintain a fle at your place of business.
1«rrA�nhei L�G'vrr; G�46 2.
3. q. \
RESTAl7RANT SEATING: TOTAL# �l ZToruL C�����G�� �-bur�(�rt�ej�8-Ov(3��\
1
OFFICE USE ONLY �
LODGING:
UCENSE REQiJIRF.D FEE PERMIT q LICENSE REQUIRED FEE PERhtIT# LICENSE REQUIRED FEE PERMIT N
B&B S55 CABIN y55 MOTEL
�NN $55 —CAMP $55 —SWIMtvIINGPOOL SSOea.
�ADGE $55 �IRAII.ERPARK $105 WFIIRLPppL $SOea.
FOODSERVICE: �
LICENSEREo UTAED FEE PERMIT# GCENSEREQUIRED FEE PERMIT# LICENSEREQUIRED FEE PERMI7'N �
0-100 SEATS $85/ CON7'INEN7'AL S35 NON-PROFIT S30
JL>�OOSEA7S �$1.60 �COMhfONVIC. S60 �VFIOLESALE $80
I o _RESID.KITCHEN E80
RETAIL SERVICE:Y'� '�
LICENSE REQUIRED FEE PF,RMI'1'q GCINSE REQUIRED FEE PERMI7'# LICENSE REQUIRED FEE PERMIT H ��
60 R. S50 >25,000sy ft. y225 VENDING-FOOD E25 ��
_QS;�Osq.ft $80 �ROZENDESSERT.$40 _COBACCO $95
NnnTecxnNce: sis AMOUNTDUE _ $�_ �,
*•"*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM"••*" .Z�O,OO ��
��B �� � �� �I�
AD1I�IINIS1'RATION
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 dces not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSi7RANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED,OR
CERT.OF INSURANCE ATTACHED_
OR
WORKER'S COMP.AFFIDAVIT SIGNED AND ATTACHED
Town of Yazmouth taxes and Iiens must be paid prior[o renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For puqwses of the limitations ofMotel or Ho[el use,Transient occupancy shall be
limited to the temporary and short tertn ocwpancy,ordinarily and cus[omarily associated with motel and hotel use.
Transient ocwpants must have and be able to demonstrate that they maintain a principal place of residence
elsewhere.Transient ocwpancy shall generally refer to continuous occupancy of not more than thirty(30)days,and
an aggregate of no[more than ninety(90)days within any six(6)month period. Use of a gues[wilt as a residence or
dwelling unit shall not be considered transient. Occupancy that is subjec[to the collection of Room Occupancy
Excise,as defined in M.G.L.c.64G or 830 CMR 64G,as amended,shall generally be considereA Transient.
POOLS
POOL OPENING:All swimming wading and whirlpools which have been closed for[he season must be inspected
by the Health Depaztrnen[pnor to opening. Contact the Health Department to scheduk the inspecNon three(3)
days prior to opeuing.PLEASE N01B:People aze NOT allowed to sit in the pool azea un[il the pool has been
inspected and opened.
POOL WATER TESTING: The water must be tes[ed for pseudomonas,total coliform and standard plate count
by a State certified lab, and submitted ro the Health Departmen[three (3)days prior to opening, and quazterly
thereafter.
POOL CLOSING:Every outdoor in gound swimming poo!must be drained or covered within seven(7)days of
closing.
FOODSERVICE
SEASONAL FOOD SERVICE OPEHING:
All food service establishments must be inspected by the Health Departrnert prior to opeuing. Please contact[he
Health Depaztment to schedule the inspec[ion tkuee(3)days prior to opening.
CATERING POLICY:
Myone who caters within the Town of Yarmou[h must notify the Yarmouth Health Deparhnent by filing the
requued Temporary Food Service Application foan 72 hours prior to the catered even[. These forms can be
obtained az the Health Departrnent,or from the Town's website at www.varmouth.ma us under Health Departmerrt,
Downloadable Forms.
FROZEN DESSERTS:
Frozen desserfs mus[be tes[ed by a State certified lab prior to opening and monthly thereafter,with sample results
submitted to the Health DepazhnenG Failure to do so will result in the suspension or revocation of your Frozen
Dessert Permit un[il the above tevns have been met.
OUTSIDE CAFES:
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation,or display of any food product by a retail or food se�vice establistunent is prohibited.
NOTICE:Permits run annual ly from January L to December 3I. IT IS YOUR RESPONSIBILITY 7'p RETURN
Tf�COMPLETED RENEWAL APPLICATTON(S)AND REQUIRED FEE(S)BY DECEMBER l3,2013.
ALL RENOVA7'IONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTAIG, NEW '
EQUIPMENT,ETC J,MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A STTE PLAN. ��..
DATE: � SIGNA7'URE: �����r(�+�
PRINTNAME&TI1'LE: ( '�i-�' tfin�ta-r �i(r6/ " �i��(�/�-� �.
Rev.IOPoB/13 �� '�
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�c_c����`rr.i CERTIFICATE OF LIABILITY INSURANCE �"'�` ""�'
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Tl�S CERTIFICATE IS ]SSUED AS A MATTEA OF]NFORMATION ONLY AND CONFERS NO RIGMS UPON TNE CERTIFICATE XOLDER. THIS
CERTIFIGTE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, IXTEND OR ALTER THE COVEAAGE AFFORUED BY THE POL]C]ES
BELOW. TH75 CERTIFICATE OF INSURANCE DOES NOT CON5T1TlJfE A CIXJTRACT BETWEEN THE ISSUING INSURER(S), AU7HORIZE�
AEPRESENTATIVE OR PRODUCER AND lHE CERTIFICATE HOIDER.
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terms aM oondtlw� ot[M po%cy, certaln pallclps may reqWre an en0wsenmt A 9a[emm[ on tMs ceRlFlra[e tices no[mnfer nghts to tl�e
certlflca�halda In Ileu of wd�endorsemen[(s}
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EXCLtSI0N5AND OONDITIONS OF SUCHPOLICES.LMIfS 910Y�T1 MpYHAVEBEEN REWCED BYPAD CLAIMS.
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87 Kinga Cireuit Yarmouth Port,MA 02675
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SHDUIDANYOFTHE P80YE OESQ21ffDPOLItlES BE CAlCELL�BffORE
THE EXPIRATION DAIE THEREOF,NOTICE W ILL BE OELIVERED IN
Town d Yarmouth A�COfaAPCE WfR771E POLILY Pqpy�SqNS.
7746 Route 28
Soulh Yarmouth,MA 02684 .,. ,.-; ♦. ., �-: f'
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Client#:315701 KINGSWAYG
ACORD� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYWY)
5/O5/2015
TMIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TNIS
CERTIFICATE DOES NOT AFFIRMATIVEIY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.TMIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TME ISSUING INSURER(S),AUTNORIZED
REPRESENTATNE OR PRODUCER,AND TME CERTIFICATE MOLDER.
IMPORTANT:If the certiflcate holder Is an ADDRIONAL INSURED,!he pollcy(ies)must be endorsetl.H SUBROGATION IS WAIVED,subject to
the terms and condilions of the policy,certaln policies may requlre an endorsement.A stafement on this certificate does not eonfer Aghts to the
certificate holder in Ileu of sueh endorsement�s).
PRODUCER �E:
HUB International New England P�NNo �,978 657-5100 � N„ 866-475-7959
299 Ballardvale Street noon�ess: nee.certifiwtes@hubintemational.com
Wilmington,MA 01887 INSURER�S)AFFOROINGCOVER�GE ru�cp
978 657-5100
iNsursena:Arbella Mutual Insurence
iNsurseo
Kings Way Grille Inc INSURER B:
84 Kings Cll�cuit INSURERC:
Yarmouth Port, MA 02675 INSURERD:
INSURERE: �
INSURER F:
COVERAGE$ CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFV THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEENISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIeE� HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TRR TYPE OF INSURANCE ADULSUBR POLICV EFF POLILV E%P
IN R NND POLILY NUMBER MMIO MM/D �1MR5
A GENERALLIABILITY 8500063591 ��Os�20�$ Q�/06/Z0� EpAqC�.�Hq�OCCTURRENCE $� OQQ Q��
X COMMERpALGENERALLIABILITV PREMISES EaE�rrenca 8300000
CLAIMSMADE ❑OCCUR MEDEXP(Myoneperson) SSOOO
X LiquorLiability ;1M/E2M PERSONALBADVINJURY E� OOO�OOO
X Non Owned/Hired Auto Liab E1M GENE(iALAGGREGATE s2,000,000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGCa $Z�OOO�OOO
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WORKERS COMPENSpTON WC STATU- OTH-
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A Contents 8500063597 1/O6/2015 01/06/201 550,000
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DESCRIPTION OF OPEMTONS I LOLATONS I VENICLES�AMach ACORD 701,AEtlitlonal Rama�lce SchMUM,M mon spaa Is rpul�aE) �
CERTIFICATE HOLDER CANCELLATION
Town of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TNE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
1746 Route 28 ACCORDANCE WRH THE POLICY PROVISIONS.
South Yarmouth,MA 02664 �..
AIRHORIZED REPRESEMIITIVE �.
�1988-2070 ACORD CORPORATION.All rlghts reserved. �
ACORD 25(2010I05) 1 of 7 The ACORD name antl logo are registared marks of ACORD
#51374970/M1292402 DK004
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� The Commonwealth ofMassachusetts PrintForm
Deparhnent of Industrial Accidents
Office oflnvestigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
A�ulicant Information Please Print Leablv
Business/Organization Name:�;,�g s l il4K 62.u�s (nr c
Address: ( ` f
City/State/Zip: o Phone#: �?tF � 30 3�7 v
Are you an employer?Check the appropriate box: Business Type(reqaired):
1.�I am a employer with�(�employees(full and/ 5. ❑ Retail
or part-time).* 6. [�estaurantBaz/Eating Establishment
2.❑ I am a sole proprietor or parmerslup 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 aze a coiporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.Q Manufacturing
no employees. [No workers'comp.insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organizalion,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑Other
"Any applican[tha[checks box#I must also fill out the section below showing[he'v workers'compensafion policy informafion.
`*If[he coryom[e officers have ezempted Wemselves,but[he corporation has o[her employees,a workers'compensa[ion policy is required and sucL an
organimtlon should check box#1. �
I am an employer that is provAiding workers'compensation insurance for my employees. Be[ow is the policy information.
Insurance Company Name:_/-�C d,\i sL �A/C• C n
Insurer°snaaress'Po 8aoc 93�
City/State/Zip: �i . t rS ) �`I J O I
Policy#or Self-ins.Lic.# 6JL^1O -ZA -Oeo �L A� - o a Expiration Date: 2Q(
Attac6 a copy of the workers'compensation policy declara4on page(sLowing the policy number and eapiratian date).
Failure to secure coverage as requued under Sec[ion 25A of MGL c. 152 can lead to the imposition of crnninal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the foim oFa STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised U�at a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerkfy,under the pains and penalties ofperjury that the information provided above is true and conect
Sienature' bE.�//'f/h� �Gn a� Date' p�� � �
Phone#:
OJJicial use on[y. Do not write in this area,to be completed by cuy or town o,�ciaL
City or Town: Permif/License#
Iss"�Authorily(circie one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other i
Contact Person: Phone#: '
I
www.mass.gov/dia -.