HomeMy WebLinkAboutApplication and WC . a TOWN OF YARMOUTH BOARD OF H�1�'�'. 9 U2RN�
��� APPLICATION FOR LICELY��I ��2n1 � ^'
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Please complete form and attach all nec���en y De emb��S ZOT'B.
Failure to do so will result in the r of your applicat�on ac et.
HEALTH DEFT.
ESTABLISHMENT NAME: TAX ID: S�
LOCATION ADDRESS: TEL.#:
MAILING ADDRESS: � ca ' � /9'S ✓L � !' '%o�
OVVNER NAME: �
CORPORATION NAME (IF LICABLE): � ���
MANAGER'S NAME: Glt TEL.#:
MAILING ADDRESS: / �_� �w{�t �,�
POOL CERTIFICATIONS: �/ '
The pool supervisor must be'cck i �ed as a Pool Operator,as required by State law. Please list the desienated
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
Commwiity Cardiopulmonary Resuscitation(CPR). Please list these employees below and attach copies ofemployee
cei7ifications to tlus fornt. 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 aze required to have at least one fiill-time employee who is certified as a Food
Protection Manager, as defined in the State Sauitaiy Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of ceitification to this application. The Health Department will not use past years'records.
You must provide new copies and maintain a Gle at your estabiishment.
i._ �;c_Gr,,t�—� f��/t1�S z. �/�S/�S�/��
—,—
PERSON IN CHARGE:
Each food establishment ust have at least one Person In Charge (PIC) on site during hours of operation. I
i. �. C62t� C;J�i/✓� 2.�Ss� /��C�
HEIMLICH CERTIFICATIONS:
All food service establishxnents with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises.at all times. Please list yow• 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 �le at your place of business.
1. Z'c�.� `l�n-�r 2. Eh� M�l L��
3. . �„� 4.
RESTAURANT SEATING: TOTAL # r
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PER'�III'# LICENSE REQUIItED FEE PER�IIT fi LICENSE REQUIRED FEE PER1�IIi F
B&B S55 CABIN S55 MOl'EL S55
R�'N S55 CtVYP 555 SWL'�i�i IING POO:, S80ea.
_LODGE SSS _I'RAII.ERPARK 5105 _��'HIRLPOOL 580ez.
FOOD SER\'ICE: ��
LICENSE REQUIRED FEE PERYIIT# LICENSE REQL7RED FEE PER\u7- LICENSE REQUIRED FEE PER�fII'#
_0.100 SEAiS S85 _CONTINENI'AL S35 NON-PROFI2 S30
�>1005EATS S160 �–Q7 �COMMONVIC. S60 �(L�y� _NHOLESALE S80 ��.
REI'.�IL SER�'ICE: —RESID.KIiCHEN S80 �
LICENSE REQIDRED FEE PER'�f[I'#? LICENSE REQUIRED FEE PERbIII'r LICENSE REQU[RED FEE PER'�1IT�
_<SOsq.it. S50 � _>2S,OOOsq.ft. 5225 _dENDING-FOOD SZS
_QS,OOOsq.t?. S80 _FROZENDESSERT 540 TOBACCO S55
�.��cE c��cE: sis AMOUNT DUE = S 2��O�
� "**°*PLEASE'ILR\OVER A\D COYiPLETE OTHER SIDE OF FOR�I"*"** I
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ADMINISTRATION ' I
I
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 Inswance. THE ATTACHED STATE WORKER'S COMPENSA1'ION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED� !
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED� i
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of yow permits. PLEASE CHECK i
APPROPRIATELY IF PAID: '
YES� NO
R3QlTEL$A.�I1D a'��'�,*''„R L^v'.'�i',:14'G :'..�'Tn.�Li.�IIPiYEi'F$
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be j
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 Health Depaztment prior to opening. Contact the Health DepaRment to schedule the inspecpon ttuee(3)days
pnor to opening.PLEASE NOTE: People are NOT allowed to sit m 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.
Pf�01.CI.USING: 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 establishments must be inspected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspecUon 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 Towds website at www.varmouth.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 CAFES: I
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have_prior approval fr�m th�BQard ofi3eahh. ____
- - - _ i
OUTDOOR COOHING: �
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pemvts run annually from 7anuary 1 to December 31. TT IS YO.TR RESPONSIBII.ITY TO RETURN �
THE COMPLETED RENEWAL APPLICATION(S) t1ND REQUIItED FEE(S)BY DECEMBER I5, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQUIl'MENT,ETC.�, MUST BE REPORTED TO AND APPROVED BY Tf�BOARD OF HEALTH PRIOR
TO COMMENCE NT. RENOVATIONS MA I A SITE LAN. '
DATE: / / SIGNATURE: � � f
PRINT NAR4E&TITLE:_ d��� ����,qyyGS
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,4co d CERTIFICATE OF LIABILITY INSURANC�,�„ °"�,,,Zo'"""°o"""
^Ro°°�E" La:kton Compviies,LLC-i Kenfes City THIS CERTIFICATE IS ISSUED AS A AMTTER OF INFORMATION �
444 W.47M Sorcec.Sui�e 900 ONLY AND CONFERS NO RIGMTS UPON THE CERTIPICATE
KansasCiryM064tt2-1906 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
18�6)�� ALTER THE COVERAOE AfFORDED BY THE POLICIES BELOW.
INSURERS AFPORDING COVERAGE NAIC#
B1°��� O'CHARLEY'S,INC. iNsuf�n� ZURICH AMHRICAN INSURANCECO.
�4� ATTN: STEPHANIE BOOTH MeuREn& j,exin on In u�mlco Con an 19437
3038 SIDCO DRIVE iNeUqEnC LIBBRTY MUTUAL flRE INSURANCE CO.
NASHVILLE 7T 3726M1 �
maursea o:
INBURER E:
COVERAGES OCHIN01 DA '"�T80F�rAmconvnooueaunnepmmuie�q�nea
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 133UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREA�Nf,TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMEM 1NRH RESPECT TO WHICH THIS CERTIFICATE MAY BE IS6UED OR
MAV PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL hIE TERMS.EXCLUSIONS AND CONDITIOMS OF SUCN
POLIdE3.AGGREGATE LIMRS SHOWN MAY W1VE BEEN REDUCED BY PAID CLAIM6.
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X LIQUORLIAB.EI.SM pERsoN�L6AWINJURY i I,000.000
OENERqI.A(iCYiEOATE S 4�000.000
(iEMLAOOREOATELNIRAPPLIESPER: PROWCTS-COIplOPRGO S �OOOIXIO
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an�uio NOTAPPLICABLE m�Rn� EnnCc S XXXXXXX
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A e�oreqg�u�ex.m Y/N WC9137280.04 4/15/2010 Mi5/2011 X �STATU- a .
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PROPER7Y IALL SUB1ECf TO SUBLMTS 8 DEDS
RISK/RC) IOM O0.D/ICC
OEOCRPIION OF OPERMIONB/LOCAiIONB/VEXICLE81 EXGLU610Nt 110DmlY BlDW7JEABRf EPECIAL PROVIlIONB
APPLICABLE DEDUC776LE A RETENTIONS MPLY. ••THE COVERAGE LISTED ABOVE DOES NOT EXTEND ANY FURTHER THAN WHAT IS
REQUIRED BY THfi LFASE/CANTRACf SUBJECT TO TERMS AND CONDITIONS OF POLICY.��RE:99 RESTAURANT-PUB#2�30,14 BERRY AVE.
WEST,YARMOUTH,MA 0267J
CERTiFICATE HOLDER CANCELLATION
2118980 aHw�ourrovrnEneoveor�uusEova�c�seeeawe��oa�sorten�exwn�non
TOWN OF YARMOUTH CAh TMEREOF�TME OEIRNO INBURER WILL ENDFAVOR TO IWL 30 onra WRmEN
46 ROUTE 26 SOLTH norice m rxe cennFlcn��o�.00e rureoro n�e�eFr,eur F,uwne ro 0o so axw�
YARMOUTH MA 0?664 plpo6E No OBLIOATOt1 oR uABWrY oF ANY qlo UPaI TNE INSUR6t,ir8 AGEwr6 oR
� lIEPR�ENTATNEB.
RE9ENTATIVE
ACORD 25(2009/01) �1988- CORPORATION. AII rfghts reserved.
TM ACORD nane and lopo ara registered marks of ACORD
Po.w.e.�.�w�u uu.�.dM.m w�..�e..n�w m w waaue.r..�uen.ew.ae w.�Mr a.wix wa mw�m•.
. �
j � � The Commonwealth ojMassachuseus
Department of IndustrialAccisdentc
Office ojlnvestigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Inaurance�davit: General Bnsinesses
� Apalicant Information Please Print Leeiblv
Business/Organization NamP•99 West, Inc. dba 99 Restaurent&Pub
Address: �4 Berry Ave�ue
City/State/Zip: Yarmouth, MA 02673 Phone#: (508)862-9990
Are you an empbyer? Check the appropriate boa: BoB�oess Type(reqdred):
1.� I am a employer with 79 emplayees(full and/ 5. ❑Retail
or tune .* 6. �RestaiaantBar/Eating Establishment
P�-� )
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,suto,etc.
employees working for me in any capacity. 8. ❑Non-profit
o wmkers'comp.insurance required] 9. ❑Entertainment
3.❑ e are a corporahon and its officers have exercised
their right of exemption per c. 152§ 1(4),and we have 10. 0 Menufactuting
no employeees. [No woke�'comp.insucance required]s• 11. � Health Care
4.❑ We are a non-profrt org iration,staffed by voluntxrs, 1Z. � ptha.
with no employces. [iTo workers'comp.insurance req.j
'�Y evv�rmt th�eLa�ks bwc#t mist al�fill out the sectia�bdavs6owmR their�vlcas'canp�i�WlieY infamazion.
*�If the enpavete offims have«empted themulves,b¢the mpaatim Ins othc m�ployees,e.w�kets'compeaaeam poficy is Rquirtd mid surh� �
organi�tion should d�eck box#l.
I am an employer thal!s provJding workers'compensatlon Grsurancejor my employees. Below fs 1he polley inforneallon.
Insurance Company Name: Zurich American insurance Co.,et al.
InsureCs Address: �a Lockton Companies,444 W.47tli St., Suite 900
City/StatelZip: Kansas City, MO 64112
Policy#or Self-ins.Lia lt WC9137280-04 E�iration Date: 4/15/2011
Attach a rnpy of the workers'coropeosation poticy declaretion page(showiag the policy nnmber and eipiratio■dste)
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead m the imposition of criminal penaities of a
fine up to$1,500.00 and/or one-year imprisonment,as well es civil penatties in the fonn of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violawr. Be advised that a copy of this statement may be forwarded to the Office of
InvesBgations of the DIA for insurance coverage verification.
I do Irereby c�', nder theJ�ains and paraltles olperJury thot the JnjornwQion provlded above u drre an eorrect
Si�edue: K N��' Date: ���/9�U
Phone#: (675)258-8500
OJJ4ciaJ nse only. Do not wNte!x th�s area,to be complued by city or town oJJidaL
City or Town: Permit/Liceose#
lssuing Authority(circle one)
1.Bosrd of Health 2.Bnilding Depertment 3.City/Town Ckrk 4.Licensing Board 5.Selectmen's Ottice
6.Ot6er
Contsct Person: Phone#:
www.mass.em m