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Home My WebLink AboutApplication and WC - i � d � TOWN OF YARMOUTH BOARD OF HEA TH` '- ` ��1C' � �� '� � APPLICATION FOR LICENSE/PE 'I'� ^� ��b . _ �;. os zo�z * Please complete form and attach all n �� od�c�umen by 20 2. Failure to do so will result in the urn �zf your ap ' � ESTABLISHMENT NAME: �`G ��.�fQi�`I TAX ID• � � I�', LOCATIONADDRESS: Y �MY� TEL.#: ', MAILINGADDRESS: 303e s�b(`7 1�'iuE � f.�1G�.511di1`�P T 3`�c�D ' OWNERNAME:��PSi' Ll I� CORPORATION NAME (IF APPLICABLE): �SCv�@ I MANAGER'S NAME: TEL.#: I MAILING ADDRESS: i(JC 0 . (. _�C(.S �}�( Q„� T l� 3'7 aD�l POOL CERTIFICATIONS: I The pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated � Pool Operator�s) and attach_a co��Qf the cer_tifcatio�Io tl�isform-_ - ---- ___— -- - _ ' �. NI-+9� Z. -- Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid and Community Cardiopulmonary Resuscitation (CPR). Please list these employees below and attach copies of i 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. 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 Tde at your establishment. '� 1. � albn, wha�IAs " z. �`os�ph J-� Gt� � p�n ep�T rnz�un T�EE:--- -- -- -- ---_------_--- °— -- —-- --_ Each food establishment must haye at least one Person In Chazge (PIC) on site during hours of operation. i. ��.�Q I ie-r �.�hc��p►as a. �o �-Ph N �� 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 file at your place of business. 1. ��,'J�lAQ1� � _4._�rh QPYI ( 3. � RESTAURANT SEATING: TOTAL# � OFFICE USE ONLY �I LODGING: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# WCENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $55 � _INN $55 _CAMP $55 � _SWIMMING POOL $80ea. I LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea �, FOOD SERVICE: '�, LICENSE REQUIRED FEE PERM[T# LICENSE REQUIRED FEE PERMI"I'# LICENSE REQUIRED FEE PERMIT# �I 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 ! � >100 SEATS $160 �-1 �COMMON VIC. $60 ��"� _�10LESALE $80 �� RETAIL SERVICE: - � —RESID.KITCHEN $80� ��.. LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �� _<50 sq.ft. $SO >25,000 sq.ft. $225 � _VENDING-FOOD $25 ��. <25,000 sq.ft. � $80 —FROZEN DESSERT $40 _TOBACCO S95 '� NAMECHANGE: $15 � AMOUNTDUE _ $ 22-0. 00 �� iI *****PLEASE TORN OVER AND COMPLETE OTHER SIDE OF FORM*•*•* ��. IV•. ... _. .... ._. .. .. . .._ - . .. . .. I � �� 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 I 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 Yannouth taaces 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 shall be limited to the temparary 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, sha11 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 De�artment to schedule the inspection three(3)days pnor to opening.PLEASE NOTE:People are NOT allowed to sit m 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�)�ays of closing. FOOD SERVICE 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 Yannouth Health Department by filing the ' requued 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.yazrnouth.ma.us under Hea1th 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 CAFES: -- —�;:.��e:.��:�et�t�c�r se�'Fng-zu=±" 'n�=t_�i-..��s�e=v� _ —_. OUTDOOR COOKING: II 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 RETIJRN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2012. 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 i'LAN. i DATE:_ SIGNATURE: V� ilG�� ,�,��_ � PRINT NAME & TITLE:_ IV C2 rX�, �� (sor� 1 1�`,( �('P Ourl f!d'�C� Rev. 10/09/12 � : , � � The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 1 Congress Street,Suite I00 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Aaalicant Information Please Print Leeiblv Business/Organization Name: �� J��.l.t/R/�� i.l-� Address � �'� ��Y Y �� "�V'Q V�(.lQ City/State/Zip:�Q f r�O(1`� 1�rJ ��(0�.3 Pnone #: b� -g�a-q�� b � Ar�e�yo an employer?Check lhgap�ropriatebaJc: _. — ;BusiaessSype(required):- , _ - 1.L•� I am a employer with�employees(fiill and/ 5. ❑Retail or part-time).* ' 6. 0'ttestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. � Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capaciry. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We aze 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]* 1 LQ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑Other I •My applicant that checks box#1 mus[also fill out the section below showing the'v workers'wmpensation policy information. . **If[he coryorate officers have exempted[hemselves,but the corporntion has other employees,a workers'compensation policy is required and such an �� organizalion should check box#1. � �'�. I am an employer that is providing workers'compensation insurance for my employees.,Be[ow is the policy information. InsuranceCompanyName: �U.! i (.h �1M2 �(� c� �SWGA lP �+C �Qn� Insurer's Address C-I � �ln D n ��' c�ri�s�c�✓z�p: tiC�shoi��Q ,1` (Jp 3��b .. _ .__.�011r)'.�C7�21�k':5:1:2�-fk_ ...�.Jr JL_.V O� 0 C)`�� .. . ��021.,�'dtC:______—. _.—' . ._____._. . ''. Attach a copy of the workers' compensaHon policy declaration page(showing the policy number and espiration date). I Failure to secure coverage as required under Sec6on 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$1,500:00 and/or one-yeaz imprisonment,as well as civil penalries 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 forwazded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd'fy,under the ins an penalties ojperjury that the injormation provided°�ove i true and correct. � Signature: �l ��YI Sr � �d G� Date� � I 1'��p� Phone#: Official use only. Do not write in this area,to be comp[eted by city or town officiaL City or Town: �dyNNOUQIl- Permit/License# � I circle one): 1.Board oFHea 2. Building Department 3. City/Town Clerk 4.Licensing Board 5.Selectmeds Office , 6. Contact Person: Phone#: cSZ��'!S c�-a3� X/Z�(/ ' � - . . wwu•.ma.s.go�a'di;. �. � . '�.. i � ACQRO• onreRanvoomvr� �� CERTIFICATE OF LIABILITY INSURANCE Page 1 of Z oa�oz�2oiZ THIS CERTIFICATE IS ISSUED AS A MAttER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOIDER.THIS . CERTIFICATEDOESNOTAFFIRMATIVELYORNEGATIVELYAMEND,EXTENDORALTERTHECOVERAGEAFFORDEDBYTHEPOLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORI2ED REPRESENTATIVE OR PRODUCER,AND THE CER7IFICATE HOLDER. ' IMPORTANT: If the certiflwte holder is an ADDITIONAL INSURED,lhe policy(les)must be endorsed. If SUBROGATION IS WANED,subJect to the terms and conditlons of the policy,certaln pollctes may require an endorsement.A statement on lhis certificate does not confer rights to the certlflcate holder in lieu of such endorsement(s). PRODUCER CONrACT Nillie oE Florida, Inc. PHONE � c/o 26 ceatury slvfl. � 877- 45-7378 F� 888-467-2378 n.o. sox 305191 -M/JL certificatea�will'e.c m xaehville, TN 37230-5191 INSURER(SpiFFORDINGCOVERHGE NAICp INSURED �NSURERq� Zus3Ch Ameslcen zneurance COmpaay � 16535-005 . Ameriean Hlve Aibbon Holdinge, LLC INSURERB:�erican Guarantae & Liab. Ine. Co. 36247-001 Attn: Stephanie Latona INSURERC:7werican Zurich Ineuranee Company 90192-001 . 3038 Sidco Drive Naehville, TN 37404 iNSURERD:Laxington Inaurassce Company 19437-001 INSURER E: � - INSURERF. � COVERAGES . CERTIFICATE NUMBER:183oa581 � � REVISION NUMBER: TH;S IS TO CERTIFY THAT TYE P`JL'CIES OF INSUR4NCE LISTED BEIOW�HAVE BEEN ISSUED Tp THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO7WITHSTANDING ANV REQUIREMENT,TERM OR CONOITION OF ANY CONTRAC7 OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAV 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 rypEOFIN3URANCE DD' SUB POLICYEiF POLICYE%P POLICV NUNBER LIMRS A GENErsnLLIqBILm OL0387$54000 $/1/2012 B/1/2013 EACHOCCURRENCE S 1 O00 O00 X COMMERCIALGENERAILIABILITV OAMACaETORENTED PREMISES Eaa¢urence 5 1 OO OOO CLAIMS-MADE % p�CUR MEDE%P(M onepareon) E X LSUuOi LSBb S1 $M GERSONlLLBADVINJURV $ 1 O O OOO GENERFLAGGREGATE 5 AO OOO OOO GEN'L AGGREGATE LIMR APPLIES PER: PRO- PROOUCTS-COMP/OPAGG $ Z OOO OOO aouCr X �oC oli Ge A S 40 00 0 A AUTOMOBILEWBILITY BAP387854100 8�1�2012 Q�1�2013 COMBINEDSINGLELIMIT X ANYAUTO (EaaaiEeM) y 2�000�000 BODILYINJURV(Pe�person) $ ALLOWNEO SCMEDULED � AUTOS AUTOS BODILYINJUflY(Parauitlen�) 5 X HIREDAUT0.5 X NON-0WNED AUTOS (Peraccben�)AM E E 8 X UMBPELIALIAB X ppCUR AUC931218301 8�1�2012 8�1�2013 EACHOCCURRENCE E 10 000 000 E%CE53 LIAB CLAIMS-MADE AGGREGATE E lO OOO OOO DED RETENTION$ S � wa+Kerzsco.,vexsnnoN WC387853800 a/i/zoia s/i/zois x RNpEMPLOYERS'LIABILITY - C ANYPROPRIETOR/PARTNER/EXEWTIVEa N�A 4PC387B5$900 . 8�1�2012 8�1�2013 E.I.EACHACCIDENT $ 1�000�000 OFFICEfUMEMBER E%CLUDEUt � 1MantlatorylnNH) EAEMPLOYEE S S�OOO�OOO tlyes tlesuibeuMer E.LDISFASE� DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMIT $ 1�000�000 D Co�l Proper[y 017728230 6/30 2012 6/30 2013 Bldg/BPp/Stock/eI ' � � ' � $350-,000.000 elanket Limit Special eorm � Replacement Caat $50,000 AOP Deductible DESCRIiTION OF OPERATONS/tOCATION3/VEHICLES(AHaeh AeoM 101,AtltlXonal Ramarka Schedulu,Hmon apau in requlretl) See Attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 7HEREOF, NO710E WILL BE DELIVERED IN ACCORDANCE WITH THE POLICV PROVISIONS. AUTHORREDREPRESENTATIVE Bvideace of Coverage . . � Co11:3814758 Tp1:1497839 Cert:18306581 �1988-2010ACORDCORPORATION.Allrightsreservetl. ACORD 25(2070/OS) The ACORD name and logo are registered marks of ACORD . r ' AGENCY CUSTOMER ID: 22010529 LOC#: A�e ADDITIONAL REMARKS SCHEDULE Page2 of .� AOENCY NAMEOINSURED � Willia of Florida, inc. 7�merican Blue Ribbon Holdings, LLC Attn: Stephanie Latona POIICYNUMBER 3038 $1QC0 DLiVB � Naehville, TN 37204 See Firat Page CARRIER NAIC CODE See Firet Pa 9 EFFECTNEDAIE: SHB Firet Pa e ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ZS FORM TITLE: CBRTIFICATB OF LIASILITY IN3URANCE . Property Deductiblee: Sublimite aad Deduotiblea: Deductible - All Other Perila $50,000 par Occurrence except; Harthquake eublimit $SOM excep5t; � Deductible SarthquZake an2�$any onecoccurrencenin New Madrid and Pacific N[4 Zones, subject to a minimum of $250,000 Deductible Sarthguake - $100,000 any one occurreace other than above Flood eublimit $SOM except; $lOM SPAA Zone Deductible Flood - $100,000 aay one occurrence except; Deductible Flood - $250,000 3FHA Zone or 5$ of TIV, eubject to a minimum of $1M Namad 4Pindetorm eublimit $25M Tiar 1 Countiee Deductible Named Windstorm - $50,000 per occurrence except; Deductible Named Wiadetorm - Sis of TIV Tier 1 Countiea, aubject to a minimum of $250,000 24 Hour Waiting Period Service Interruptioa ACORD701 (2008/01) Co11:3814758 Tp1:1497839 Cert:18306561 02008ACORDCORPORATION.AIIHghffireserved. The ACORD name and logo�are registered marks of ACORD