HomeMy WebLinkAboutApplication and WC _ _ _ �
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� a TOWN OF YARMOUTH B0�1RA O�-HE,AL'F�r�. yA� �V� N S�
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��� APPLICATION FOR LICEN�E(P�1tMIT�- �Q�d' ;,,,,, l�Q�;�
` * Please complete form and attach a11 nec�s`sa�q�s��s`firy ce
Failure to do so will result in the rehun of your applicati "
ESTABLISHMENT NAME: ��a« S«�: �� 4�.,� [..R �zSl�.Ati TAX ID• �`��.- �
LOCATIONADDRESS: )�£ �-or<,� A�c "w.-...��.. M�A TEL.#: SoS- �ti8- so�o
MAILINGADDRESS: l�v �a< ts�� So.n�. 0�..:, rq o1i9Vo
E-MAIL ADDRESS: .�r.�, �.- c�: . �
OWNERNAME: c��w..r 5.�.�:.,., ,.� �� [�s � ��.. 3.s��a, , � .,� .
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: C�:� Y�,,,��_, - `SG�Mar�� S;at [�,....st. TEL.#: s��- 3as- so�o_
MAILING ADDRESS:
POOL CERTIFICATIONS: '
The pool supervisor must be certi£ed as a Pool Operator,as required by State Iaw. Please list the designated Pool
Operatar(s) and attach a copy of the certification to this form.
L 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and
Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at a11 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. 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 certificarion 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. G�.: \ I"��...r�... — 5��� Csz,r.,�. 2.
PERSON IN CHARGE:
Each food establishxnent must have at least one Person In Charge (PIC) on site during hours of operation.
1. Gw� r�.,n�� 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.
l. �J..nti \7��;��..y�1.: 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one em�loyee 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.
l. Cs�.: n� 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 $55 �
INN $55 CAMP $55 SWIMMINGPOOL $80ea
—LODGE $55 T2AILER PAI2K $105 _WHIRLPOOL $SOea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE P�RMi i#
0-I00 SEATS $85 _CONTINENTAL $35 �NON-PROFIT $30 �k
>I00 SEATS $160 _COMMON VIC. $60 WHOLESALE $80
— —RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERM[T#
=<25q >25,000 sq ft. $225 VENDING-FOOD $25
,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 3O.oC;
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***'"
`I
ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal6f
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 INSiJRANCE ATTACHED ✓
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED__� '
Town of Yannouth taxes 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 of 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 shall generally refer to continuous occupancy of not more than thirty(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 collection 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 Heaith Department prior to opening. Contact the Health Departrnent to schedule the inspection three (3) days
prior to opening.PLEASE NOTE:People aze 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
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.
_ _ __ _— -- - - _ _ _ FGDD SEAVICE .
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 72 hours prior 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
submitted to the Health Department. Failure to do so wiil result in the suspension or revocation of your Frozen Dessert
Permit until the above terms have been met.
OUTSIDE CAFES:
Outside cafes (i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health.
OUTDOOR COOHING:
Outdoor cooking,prepazation, 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 DECENIBER 13, 2013. ,
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW '
EQUIl'MENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO '
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: lz I S/7 SIGNA"I'[JRE: ��1��_
PRINT NAME&TITLE: £d�:c C�..���.,� - N�a r:�; Q n.�r, ��..�«
Rev. 10/OS/13 .
Client#:39689 ELDERSERVN
ACORD�, CERTIFICATE OF LIABILITY INSURANCE °"'�""°"°°"�"'�"'
70@5/2073
THIS�CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSi1TUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND TIiE 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 polieies may require an endorsement.A statemeM on this certificate does not confer rights to the
cert�cate holde�in lieu of such endorsement(s).
PRODUCER �E^. -Chris Hedetniemi
HUB Intemational New England o�NN .508-945-7864 N,; 508-945-9136
265 Orleans Road E,�i�
North Chatham,MA 02650 AD°��`
506 945-0446 MSURER(S)AFFORDING COVERAGE NpIG R
ixsursFo
insursErea:Hartford Casualty Ins Co
Elder Services Of Cape Cod& INSURER B:
The Islands Inc u+surseRc:
68 Route 134 u+sursoeo:
S Dennis, MA 02660 �NSURERE:
INSUitERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERi1FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO�
INDICATEO. NOTNITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTH'cR OOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCftIBED HEREIN IS SU&IECT TO ALL THE iERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. IJMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS.
AOD SUB
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GENERqL LIqgIL1TY
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DESCRIPTION OF OPERqTIONS below E.L.DISEASE-POLICY LIMR $'I�OOO OOO
DESCRIPTION OF ppERAT1pNS/LOCATIONS I VEXICLES(Alqr.h pCORD 701,qtlEitlonal Rema�ka Schatlula,M mpre apaco Ie requlred)
� CERTIFICATE HOLDER CANCELLATION
SHOIILD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE
THE E7�IRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WffH THE PO4CY PROVISIONS.
AUfHORII�D f�PRESENTATIVE
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�7988-2010 ACORD CORPORAiION.All rights reserved.
ACORD 25(2070/OS) 1 Of 1 The ACORD name and logo are regisMred marks of ACORD
#57011068/M790429 . CH004
/� ELDESER-01 DEATON
AC�RO" w���rwoomr,�
. `.,�� CERTIFICATE OF LIABILITY INSURANCE ,,,a�2o,3
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHEPOLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSi1TUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORI2ED
REPRESENTATIVE OR PRODUCER,AND THE CER7IFICATE HOLDER
IMPORTANT: If the certiFlwte holder is an ADDITIONAI INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditlo�of the policy,certain policies may require an endorsement A statemeM on this certificate tloes not coMer rlghts to the
ceR�eate holder in lieu of such endorsement s.
P����+ °O�^� Dennfs Office
NAME:
Rogers&Gray Insurence Agency,Ine. rxor� F —
434 Rte 734 nrc No�: agJ:(877)616-2156
South Dennis,MA 02660 E�AAIL
noorsess:
INSURER(5)AFFORDINGCOVERAGE NAICk
iNsurs�e a:Selective Insurance Co.of S.C.
INSURED
INSURER B:
EltlerServices of C.C.&Islands Ine iNsurs�ec:
68 Route 734 iNsunoe o:
S.Dennis,MA 02660-3710 wsun�e e: �
MSURERF:
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. NOTMTHSTANDING ANY RE�UIREMENT, TERM OR CONDITION OF ANY CONTRACTOROTHERDOCUMENTVNiHRESPECTTOWHICHTHIS
CER7IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREINISSUBJECTTOALLTFiETERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS.
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GENERALWIBMY EACHOCCURRENCE S ��OOO�OO
A X COMMERGALGENERALUABIIJTV 57916903 12M/2012 12N/2073 pqEMISES Eaocartrence 5 ���i00
CLAIMSMADE �OCCUR MEDEXP(Myaneperson) 5 �5,00
PERSONALBADVINJURY E 'I.00O�OO
GENERALAGGREGATE S 3�000�00
GENLAGGREGATELIMITAPPLIESPER: PRODUCTS-COM%OPAGG 3 3.000�00
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLJCIES BE CANCELLED BEFORE .
""FOR CON7RACT PURPOSES"' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WI7H 7}iE POLICY PRONSIONS.
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OO 1988-2070 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD