HomeMy WebLinkAboutApplication and WC ,
' rt TOWN OF YARMOUTH BOARD OF HEALTH, _ ��U �B
, ��� APPLICATION FOR LICENSE/PERM 2�� ; ''G��C�I��M l�DD
* Please complete form and attach a11 necess� s 013
Failure to do so will result in the re o�"yo �31i�a'tion c ef." "
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ESTABLISHMENT NAME: zs+�-v rarn �zAoSo
LOCATION ADDRESS: t �$e�r r V�-nv�. TEL.#: So6 Pi Z—�t �l O
MAILING ADDRESS: �038 S'1dCc� Y i V-2>� rtJL►Sh�111-4.�T►v ��ZO
�MAII,ADDRESS: �'oyG�S@A6r holdinqS. �'_¢yr� '
OWNER NAME: �1 W2.M- I.LC ;
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: W a�-EtiY lN�'Zzxp(-2S� TEL.#. S06 �tD Z-�1q(7 ,
MAILING ADDRESS: 1'-f ��'r r�-f la V v u- � �f z►--r rv�n-�}}-{.�� 1rr1A ��-co'�-3
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.
l. lU �l�r 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 a11 times. Please list I
the employees below and attach copies of their certificaUons to this form. The Health Department will not use past i
years' records. You must provide new copies and maintain a file at your place of business. I
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS: i
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 Deparhnent will not use past years' records. You must !�
provide new copies and maintain a file at your establishment. '
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PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC)on site during hours of operation. ',
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ALLERGEN CERTIFICA ONS:
All food service establishments aze required to have at least one full-time employee who has Allergen certification,as
defined'm the State Sanitary Code for Food Service Establishxnents, 105 CMR 590.009(G)(3)(a). Please attach copies of
certification to this application. The Aealth Department will not use past years' records. You must provide new ,
copies and maintain a 51e at your establishment.
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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. Flease 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.
J i
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3.�c.b anou+uri� �-, 4. u�i-�-e- s �c.-�hz: I.c�S
RESTAURANT SEATING: TOTAL#
�
OFFICE USE ONLY �
LCEN E REQUIREQ FEE PERMIT# LICENSE REQUIRED �FEE PERMIT# LICENSE REQUIRED FEE PERMTT# �
B&B $55 CABIN $55 MOTEL $55 �
INN $55 CAMP $55 SWIMMINGPOOL $80ea '
LODGE $55 � TRAILERPAItK $105 WHIRLPOOL $80ea
FOOD SERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUtRED FEE PERMIT# i
0-100 SEATS $85 CONTINENTAL $35 NON-PROFIT $30
�>100 SEATS $t60 �� LCOMMON VIC. $60 �4-ofx3 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. $225 VENDING-FOOD $25
� <25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
1VAME CHANGE: $15 AMOUNT DUE _ $ 22G,OO
�
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•**••PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*'*** �
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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 Cer[ificate of Worker's Compensa6on
Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE
COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED V
OR /
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED V
Town of Yazrnouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK ,
APPROPRIATELY IF PAID: / �
YES � NO 'i
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: Far purposes of the limitations of Motel orHotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinazily 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 sha11 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 I
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.
POOL5
POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by
the Health Departsnent prior to opening. Contact the Health Department to schedule the inspection three (3) days
prior to opening.PLEASE NOTE:People aze 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 standazd 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
SEASONAL FOOD SERVICE OPENING:
All food service establishxnents 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.vannouth.ma.us under Health Department, Downloadable �
Forms.
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FROZEN DESSERTS: i
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results
submitted to the Health Departrnent. Failure to do so will 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 priar approval from the Boazd of Health.
OUTDOOR COOHING:
__QL�td44r 000kine. or�paration_ or disnlav of anv fa2dnrnduci_bKar�Yail.nrfaollsetvica estahlishment ;� prnlubited.
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 DECEMBER 13, 2013.
ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW �
EQUIPMENT,ETC.),MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO
COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. I
DATE: �i �Z l l l 3 SIGNATURE: �L�� � "`�� �
PRINT'NAME& TITLE: �-}n1`�Za �0 Yl r1G1 C �X ��-O'UY1��� �
Rev. 10/08/13
1
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Officers of 99 Wes� LLC
*No o�cer owns>5%of atock of corporaHon
O,pScer/Address � ��
ANRA K.ADAMS � cro�r Fm��dai oma� . .
307 DemoMreun Street � .
Nashville,TN 37201
� JOM R.GredY � 98 RateureMa'President
4 MockingWrtl Lene �
Walpole,MA 02p87 -
Hazem M.Ouf � CEO antl Presitlent
11037stAvenueNorth � ��
Nashvllle,TN 37203
GOODIOE M.PARTEE � SVP and Secretary �
4414 Curtiawood Cirde � �.
NeshWlle,TN 37204
' � TheCommonwealthofMassachxsetts
- Department of Industrial Accidents
Office oflnyestigations
600 Washington Street
Boston,MA 02I11
www.maSs.gov/dia
Workers' Compensation Inaurance Affidavit: Genera!Businesses
Apnlicant Information Please Print I,e¢iblv
Business/Organization Name: �� 1iv2 S�+ LI,C G� b, a �1�1 �QS-[�-u s—�r�`�� Pu b
Address:_�� �j2'Y r111 ►�l V�C'Xl.l�'-�.
02��--3
City/State/Zip:�,�• y?�'�'Yvl o v`�,rn� Phone#: �so� �o�r'�q�( O
Are yon an employer?Check the appropriate boz: Business Type(reqaired):
1.� I artt a employer with��employees(fiill and/ 5. ❑Retail
or part-time)." � 6. �RestaurantBar/Eating Fstablishment i
2.❑ I am a sole proprieWr or partneiship and have no �. �p����or Sales(incl.real estate suto,etc.) i
employces working for me in any capacfty. ' I
(No workers' comp. insurance requiredj 8. ❑Non-profit �
3.❑ We are a corporation and iis officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees. [No workers'comp.insurance required]*
4. We are a non- fit o 1 I.0 Health Care
� pro rganization,staffed by volunteers,
with no employees.(No workers'comp.insurance req.) 12.❑ Otlier
•AnY epplicant that checks box#1 must eLto 611 out the sec6on below s6owing their worke�s'compwisation policy infotmation. .
"If the cocporate offiar_have exempted themselyes,but ihe cotporation has otlier employees,a wadkas'compensetion policy is required and sucb eo � .
o�gmimtiuon should d�edc box#L . .
I am an e�loyer that tsproviding workers'rn�rensruion insrrmnce jor my emp/oyee,s. Below u dre policy befornmtion.
lnsurance Company Name• �rn2r� r cv� Z.� Y' C�.. �.,��.,.r�cr.cp C a� .-,.,. �
Insiuer's Address: \o o\ �u.-,....�..� �\J d.. � .� �e.., \'10�
City/�ate/'Lip: `A�\�c.. , �.-.`P�. '�03�
Policy#or Self-ins.Lic.#_ I.JC 4,``I'p S�'Q O� Expiration Date: �n � \ � a0 \�I'
Attach a copy of the workers'compensstion policy declaration page(showing the policy nambee and eapiration date).
Failure to secure coverage es required under Section 25A of MGL c. 152 can lead to the imposidon of criminal penalties of a
fine up to$I,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WURK ORDER and a fine
of up W$250.00 a day agaiast the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do kereby ceH�, weder the paLrs axd peaulHes o./�PerJury that tlre ixformatfon piovlder!above is true and corred
Sienature: �-.�,�,`.� 3��-.'_-,- Date• �4
Yhone#: �� s ��118�. �qJis
Officdal use oely. Do not wr&e ue tkls area,to be rnm�leted by city ortown officiaL
City or Town: �A�tN 0 v'i�+ Permit/License#
ia�'A�ttroeky-(c' cle one):
oard of Healt6 2. ilding Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Oflice
6.Othe
n'_._".r"'___' n�'__y' �u�JQ0���3� �C �2�� .
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A✓d CERTIFICATE OF LIABILITY INSURANCE PBgg 1 af z �oii�%ao 3
, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONPERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFPORDED BY THE POLICIES
� BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: Mthe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGA710N IS WAIVED,subject W
� thetermsandcondltlonsofthepolicy,certainpollciesmayrequireanendorsement.Astatementonthiscertiffeatedcesnotconferrightstothe
certificate holder in Ileu of such endoreemenys).
PRODUCER CONTACT
Willia lneurance eervicee of Georgia, xne. PHONe , 877_g45-7378 F� 688-4 7-2378
c/o 76 Century Blvd.
r. o. ao: 3osisi E-�� certiEicatea�willie.com �
Naahville� TN 37330-5191
INSURER(Sy1FFORDINGCOVERAGE NAIC#
INSURERA: �titich AmeilCan InBurance C�peuy 16535-005
wsuneo
O'Chasley'e LLC INSURERB:lfinericaa Guarantee E Liab. Ine. Co. Y64Q7-001
3038 81dC0 DYive INSURERC:�sican ZurSCD InBuiance CompBIIy 40142-001
Naehville, TN 37204 INSURERD:1.axi¢gton Iaeuranca Company 19437-001
INSURER E:
INSUftERF:
COVERAGES CERTIFICATE NUMBER:2060076i REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMEM,TERM OR CONDITION OF ANV 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 CW MS.
INSR TypEOFINSURRNCE $�B POLILYNUMBER POLICVEFF POLIC`/El� ��M��
j� GENERALLIABILT' GL0387854001 B�1�Z013 $�1�2014 EACHOCCURRENCE $ 1 QQQ OQQ
X COMMERCIALGENERALLIABILITY DAMAGE OREMED
PREMISE Eaoccuiance S 1 OOO O00
CIAIMS-MADE�OCCUR MEDEXP Anyonapereon) $
X LiGUOi L18b S1.SM PERSONALBAWINJURY $ 1 000 OOO
CaENERALAGGREGATE $ 40 000 000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG E 2 OOO OOO
POLICY PRo- LOC ¢ $ DO
A Auro'.went�we��m BAP387854101 8/1/2013 8/1/2019 �Ea�ItlaDSINGLELIMIT $ Z,000,000
X ANYAUTO BODILVINJURY�Perperson) $
A�OOVJNED ACUTHOESULED BODILVINJURY�Peracdtlenl) $
X HIREDAUTQS X NONAWNED P RTYDAMAGE
AUTOS (PeracciGeM) E
E
8 X u,.sBn¢�uune X pccurt ADC931218302 8/1/2013 8/1/2014 EACHOCCURRENCE 8 20 000 000
EXCESSLIAB CWMS-MADE AGGREGATE $ 2O OOO OOO
OED RETENTIONE g
C WORKERSCOMPENSATION NC387853801 8/1/2013 8/1/2014 X -
AND EI.NLOYERS'WBILITV
C ANYPROPRIETOR/PARTNERIEXECUTIVE� N�A DPC3B7853SO1 8/1/2013 B�S�aOIA E.L.EACHACCIDENT $ S�OOO�OOO
OFFICERIMEMBER EXCLU�E09
INaMaloryinNX) E.L.DISEASE-EAEMPLOVEE $ 1�000�000
Hyes,Gescnbauntler E.L.DISEASE-POLICYLIMIT E 1�000�000
DESCRIPTION OF OPERATIONS�elow
D co�1 rroperty 017728230 30/2013 6 30 2014
eldg/ePP/Btock/BI $350,000,000 B1aNcet Limit
Special Porm $ 50,000 AOP Deductible
Replacemeat COet
DESCRIPTION OF OPERAIqNS/LOCATON51 VEXICLEB(Atlx�AeorA 101,Rdtlitonal Rame�ks Sehetlule,If more apaea 6 raqui�atl)
Re: 99 Nest LLC �
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTXORREDREPRESENTAINE
8vidence of Coverage
Co11:4241632 Tp1:1683398 Cert:20600761 �1988-2010ACORDCORPORATION.Allrightsreserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD