HomeMy WebLinkAboutApplication and WC �_ -,� �� fZESf�.
TOWN OF YARMOUTH BOARD OF HEALTH '�
APPLICATION FpR LICENSE/P�II`113T1`'=2010` ""p��
'" Please complete form and attach all necessarx c�cuqi�, by,_ ec et l S a
Failure to do so witl resuit in the retum of your ap�icataon pac e�. '
NAME OF ESTABLISHMENT: �� C,S u/p V- Lt�j TEL. # .S�g��floa• �iO
LOCATION ADDRESS: `� 2��'t.
MAILING ADDRESS: j
OWNER NAME: S D r -�S S SO
CORPORATION NAME (IF APPLIC LE):
MANAGER'S NAME: � r 0.M TEL. #
MAILING ADDRESS: t�'r 2�
POOL CERTIFICATIONS: � �
'I'he pool supervisor must be certitied as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certificarion to this form.
1• 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and
Comtnunity Cardiopulmonary Resuscitarion(CPR). Please list these employees below and attach copies of employee
certificarions 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 IvIANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protecrion Manager, as defined in the State Sanitary Code for Food Service Establislunents, 105 CMR 590.000.
Please attach copies of certificarion to this application. The Health Dep»rtment will not use past years'records.
You must provide new copies and maintain a file at your estab6shment.
i. K I C,�arrc� �J�rr� cs z.__��n�ff/n-G���'w�n�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�.___ �fcl�rd �arne�g 2. ��(-��l,,� , a�r„�/
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heittilich
Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and
attach copies of employee certificarions 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. ��c�na�e� ���n t 2, Er�n IVl u 1 I i n
3. .John �-�c.��,✓,on 4.
� ,
RESTAURANT SEATING: TOTAL # �rI D
OFFICE USE ONLY
LODGiNG:
LICENSE REQUIItED FEE PERMIT# LICENSE REQUII2ED FEE PERMI'1'# LICENSE REQiJIRED FEE PERM[T#
_BBeB $55 _CABIN $55 _MOTEL $55
_,TNN $55 _CAMP $55 �SWIMbIINGPOOL S80ex.
_LODGE $55 _TRAII,ERPARK $]OS WHIRI,POOL $80ea.
FOOD SERVICE:
LICENSE REQUIItED FEE P£RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIltED FEE PERMIT#
�0-100 SEATS $85 _CONfINENTAL $35 NON-PROFIT $30
I >100SEATS $160 �`ln "6�1') �COMMONVIC. $60 �(n—�2�5 TWHOLESAL£ S80
RETAQ.SERVICE: —RESID.KITCHEN S80
LICENSE REQUII2ED FEE PERMiT# LICENSE REQUIltED FEE PERMII'# LICENSE REQUIRED FEE PERMIT#
_c50sq.tt $50 _>25,OOOsq.ft. $225 _VENDING-FOOD�$25 '
,QS,OOOsq.R. � �$80 ��� � _FROZENDESSERTS40 . � TOBACCO . � $55
NAMECHANGE:''' si's,Y, • ' '� '• " . ,-::...t r.�- . . . AMOUNTDUE _ $ 220 �oo
"""'PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM""*•*
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ADMIlVISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or pennit to operate a business if a person or company does not have a Certificate of Worker's
Compensarion 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 ATTACI�D�
Town of Yarmouth t�es and liens must be paid prior to renewal or issuance of your peimits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES� NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCI': For purposes of the limitations of Motel or Hatel use,Transieut occ•upancy shall be
limited to the temporary and short term occupancy, ordinarilq and customarily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maimain a principal place ofresidence 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 swimnvng,wading and whirlpools wiuch haue been closed for the season must be ina
by the Health Department prior to opening. Contact the Health Departmeut to schedule the inspectionthrce( )days
pnor to opetring. PLEASE NOTE:People aze NOT allowed to sit m the pool area until the pool has baen insp�
and opened.
POOL WATER TESTING: T'he water must be tested for pseudomonas,total coliform and standard plate courn
by a State certified lab, and submitted to the Heakh Depaztmern three (3) days prior to opening, and quarterly
thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or wvezed within seven(�d�ys of
closing.
FOOD SERVICE
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Sling the required
Temporazy Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the
Health Department.
FROZEN DESSERTS:
Frozen desserts must be tested on a monthly basis by a State certified lab. Test results must be sent 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:
Outside cafes(i.e.,outdoor searing with waiter/waitress service),must have prior approval from the Board ofHealth.
OUTDOOR COOKING:
U�tdoor cookina�nregazatiQn,or dispiay of any fond prQ�u�t by a r�I4r�Qd�tic���b�hment i��r4hibited. _
NOTICE:Permits run annually from January 1 to December 31. IT IS YOUR RE5PONSIBII.ITY TO RETIJRN
TFIE COMPLET'�D 1�NEVJAL APPLICATION(S)AND REQUIRED FEE(S)BY DECEMBER 15, 2009.
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 HEALTFI PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQ A STTE PLAN.
DATE: ! SIGNATURE: �
PRINT NAME&TITLE: tR-'�' t�t�r GJr lG S, �I�S���Ys�!
09/25/09
U�"�
ACORD,� CERTIFICATE OF LIABILITY INSURANCE 4„S,Zo,o °"�;;,�°9"'"'
PROpUCER Lockton Companies,LLC-1 Kansas Ciry TNIS CERTIPICATE IS ISSUED AS A MAITER OF INFORMATION
4i4 w.47th Srceet.Saire 900 ONLY AND CONFERS NO RIGHTS UPON THE CERTIPICATE
Knnsas City MO ti5112-1906 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
1816)960-9000 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC#
�N��� O'CHARLEY'S,INC. IN9uRER n ZURICH AMERICAN INSURANCE CO.
�49W ATTN: STEPHANIE BOOTH iNsunea e: Lezin fon Insurance Com an 19437
3038 SIDCO DRIVE irvsunen C: LIBeRTV MUTUAL FIRE INSURANCB CO.
NASH V ILLE TN 37?04
INSURER 0:
INSUfiER E:
COVERAGES OCHIN01 DA TM��T�^�p�pE����N�A�����ERM6
THE POLICIES OF INSUR4NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NO7WITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAV PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCE�8Y PAID CLAIMS.
��i�a o• Trre oF ixsunu�ee rouer Nureee vouar r�cmrs va.�cr exvutnnai uerts
DATE MMIDOM' DATE
GENERRL WBILT' EACH OCCURRENCE I 000 000
A X COMMERCIALGENERALLIABILITV GL09137282-03 4/IS/2009 4/15/2010 P�AISETERENTE� $ ���
CWMSMADE OX OCCUR MEDEXPMoneperson) $ XXXXXXX
X LIQUORLIAB.$I.SM PERSONALBADVINJURY $ I,000,000
GENERALAGGREGATE $ 4,000,000
GEN'LAGGREGATELIMITAPPLIESPER: PROWCTS-COMV/OPAGG $ �,000,000
X POLICY jE� LOC
AIITOMO8ILE LIFBILITY COMBINED SINGLE LIMIT $ ���
A X rwyqUro BAP9137283A3 4/15/2009 4/IS/2010 (Eaacdaenp
ALLOWNE�AUTOS BODILV INJURY
SCHEDULEDAUTOS
(Perperson) 5 .`CJC.�LI'XXX
X HIRED AUTOS
BOOILYINJURV $ ���X
X NON-0WNEDAUTOS (PeracciEent)
X COMP(],000 DED)
X COLLISION(1,000 DED ;ROPERTr DAnuGE
Perxciaenq $ .`CX7L7CXXX
6MAOELIABILITY � AUTOONLV-EAACCIDENT $ XX){,�]{XX
ANYAUTO NOTAPPLICABLE OTMERTHAN �A� $ ���'Y
AUTOONLY: AGG S �)(,�'X
E%GESSNMBRELLA LIABILITY EACH OCCUftftENCE $ Zp Q(�0 pjQ
@ X ocCUR �CwMS naoE 065302691 4/15R009 4/152010 AGGREcnTE $ zQ ppp ppp
UMBRELU $ XX.Y7CXXX
DEDUCTIBLE O FORM $ XXXXXXX
RETENTION ,�}(7Q�J(�(
A WORKERSCqAPENSATqlAND WC9137280-03 4/15/2009 4/IS/2010 X Wcsrnru- orr4
EMPLOYERS'LU&LITY TORY IMRS R
ANY PROPRIETOfLPARTNER/EXECUIIVE E.L EACH ACCIDENT § I,000�000
OFiICEfLMEMBEREXCLUDEDl E.L.DISEASE-EAEMPLOYE § I�OOO,OOO
If yes,eeacnee uneer NO
SPECIALPROVISIONSbalow E.L.DISEASE-PO�ICVLIMIT $ 1,000,0(N)
C �TMER W2-L9L-527-227-049 4/IS/2009 4/IS/2010 �SOMLOSSLMT,IOMFLD/QKE,
PROPERTY�ALL SUBIECT TO SUBLMTS&DEDS
RISK/RC) �OM ORDACC
DESCRIP710N OF OPERATIONE/LOCATIONB/VENICIEb/EXCLUSIONS ADOED BY ENOORBEMEM I BPECLLL PROVISIONe
APPLICABLE DEDUCTIBLE&RETENTIONS APPLY. ""THE COVERAGE LISTED ABOVE DOES NOT EXTEND ANY FURTHER THAN WHA715
REQUIRED BY THE LEASE/CONTRACT SUBIECT TO TERMS AND CONDITIONS OF POLICY>•RE:99 RESTAURANT-PUB#2005Q 14 BERRY AVE.
WEST,YARMOUTH,MA 02673
CERTIFICATE HOLDER CANCELLATION
2718980 sxou�o un'or'n�e�eovE oEscwaeo vouc�s ee cnwc��o aeFo�n��cvm�now
TOWNOFYARMOUTH �ATETIEREOF,THE188UMIONlSURERMIIlLENOENVORTOMNL JO pqYSWRITTEN
46 ROUTE�8 SOUTH NOTICE TO TNE CERTIFICFiE HOLDER NRMED TOIXE LEFT,BUT FAILIIRE TO DO SO SIWLL
YARMOUTH MA 02665 IMPOSE NOOBLIWTON di LIq81UfY OF AMY KIND IIPON TNE IN9URFR,ITS AGENTS OR
REPRESENfAlNE8.
NTRl1VE
ACORD25(2001/OS) F^�o�..ue�.r.a«u�c�nN,.�enmw,wwam.i..�s..x.remu.•v,oeW.+r..me�m...�w.o.��rrn.a w+'. �ACORDCORPORATION1968
r
20050
� The Commonwealth ofMassachusetts
, Deparhnent of Industrial Accisdents
Offue of Investigations
600 Washington Street
Boston,tNA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Apalicant Informarion Please Print Leeiblv
Business/Organization Name•99 West, Inc. dba 99 Restaurant&Pub
Address �4 Berry Avenue
City/State/Zip: Yarmouth, MA 02673 Phone #: (508)862-9990
Are you an employer? Check the appropriate boa: Business Type(required):
63 5. ❑Retail
1.� I am a employer with employees(full and/ 6. � Restaurnc�UBaz/Eating Establishment
or part-time).'
2.❑ I am a sole proprietor or partnership and have no �, ❑ Office and/or Sales(incl.real estate,auto,etc.
employees working for me in any capaciTy. 8. ❑Non-profit
fNo workers'comp. insurance requ'ued] 9. ❑Entertainment
3,❑ we aze a corponuon and its officers have exercised
their right of exemption per a 152§ 1(4),and we have 10. ❑Manufacturing
no employeees. [No wokers'comp. insurance required]** 11. �Health Caze
4.❑ We aze a non-profit organization, staffed by volunteers, 12. � pther
with no employees. [No workers'comp. insurance req.]
'My applicant tf�at�ecks box#1 must aLso Sll out the section below showing the'v aa�kas'compe��sati�policy inforsnation.
"If the corpolate officas k�ave exanpted theroselves,b�a the coryoration tias other�ployces,a wnrlceis'compensation policy is requimd�d such an
o�ganiTatiai should check box#1.
I am an employer that Is providing workers'compensation insurance jor my employees. Be[ow is the policy information.
insurance Company Name: Zurich American Insurance Co., et al.
Insurer's Address: �o Lockton Companies,444 W. 47th St., Suite 900
City/State/Zip: Kansas City, MO 64112
Policy#or Self-ins.Lic.# WC9137280-03 Expiration Date: 4/15/2010
Attach a copy o[t6e workers'compensation policy declaration page(showing the policy number and eapiration date)
Failure to secure covenge as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisomnent,as well as civil penalties 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 oFthis statement may be fonvarded to the Office of
Investigations of the DIA for insurance coverage verificatioa
/do hereby c under the p ins nnd penaUies of perjury that the information provided above is true an correcG
Si�ature: Da�. 11/5/2009
Phoae#: (615)256850
Officia!use only. Do not write!n this area,to be completed by ciry or town officlaL
City or Town: Permit/License#
Issuing Authority(circle one)
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Oftice
6.Other
Contact Person: Phoue#:
www.mass.¢ov �a