HomeMy WebLinkAboutApplication and WC� �. . �
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� � �^ � TOWN OF YARMOUTH BOARD OF HEALTH,� ti ����1
f APPLICATION FOR LICENSE/PERMIT-201�3,n'p �_
��' -�� � � NC�`,� �J � 2012 <<�,
* Please complete form and attach all nece $o�cnme�b}�ec mber 15 201 .PT �
Failure to do so will result in the ret��of�vtxf application ac
ESTABLISHMENT NAME: fUL��E�s Pl9CI�AE� cS�D�E TAX ID:
LOCATIONADDRESS: �'S� 11UT� � TEL.#: �D$ �7.5 Otill
MAILING ADDRESS:
OWNER NAME: CNEi2.S/ �('�42�P F"
CORPORATION NAME ( F APPLICABLE): 7 SP G.
MANAGER'S NAME: C/IFK�/L M�A,�.P,P' TEL.#:(o/7 /Io -��p �S
- MAILINGADDRESS: 3/ P��1 FSK � �rs� DFfllN/SAblZ7" MA �� 39
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool O�erator{sl a*11aYtach�r.nn}�o_f the c�rtificaticin to this fonn. - -- _ --
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standazd First Aid
and Community Cazdiopulmonary Resuscitation (CPR). Please list these employees 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. 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 Deparhnent will not use past years'records.
' You must provide new copies and maintain a Sle at your establishment.
1. 2.
- - -:�Si�f3d�I.�nfrE:- - -- _ -- - -- - - — — -- _ _ _ _ _ _
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
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-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.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT#
B&B $55 _CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SW'IMMING POOL $SOea
_LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30
>100 SEATS $160 COMMON VIC. $60 WHOLESALE $80
RETAIL SERVICE: —RESID.KITCHEN $80
WCENSE REQUIRED FEE PERMIT# i,ICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�<50 sq.ft. $50 �-�p _>25,000 sq.ft. $225 � _VENDING-FOOD $25
_<25,000 sq.ft. $80 _FROZEN DESSERT $40 LTOBACCO $95 �(��op
NAME CHANGE: $15 AMOUNT DUE _ $ ��5.o0
*****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 Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES � NO
MOTEI;S AND OTAEI2 LODGING �STAB3.ISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 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 tUirty(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 Department priar to opening. Contact the Health Departxnent to schedule the inspection three(3)days
priar 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 priar 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 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 Departrnent 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.varmouthma.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:
_ Outside cafes-(i.e.,outdoot seat'r��i2hwaiterlwaitres�service),m��st have�priar appreual£mm the Ro�l-ofl�ltl�- --
OUTDOOR COOKING:
Outdoor cooking,preparation,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 RESPONSIBILIT'I'TO RETURN
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 COIviMENCEMENT. RENOVATIONS MAY UIRE A T LAN.
DATE: 7O'J�O"�a2 SIGNATURE: ����'�7/LP/1^`—"
T PRINT NAME& TITLE: � ' /`,I �lJ�N'�
Rev.10/09/12
11/27/2012 88:57 17612931366 SORHEK INS PAGE 02102
.�'1 Op ID�AD
'4�a-R�'� CERTIFICATE OF LIABILITY INSURANCE oaiEl�+�Dorrrrn
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?HIS CERTIFICATE 19 ISSUED AS A MA7TER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATNELY OR NEOATIVELY AMEND, EJ(TEND OR ALTER THE COVERAOE AFFOR�ED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE7WEEN THE ISSUING INSURER�S�, AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CER'i'IFICATE HOLUER.
IMPORTANT: It thB certfNcate�oldef ig 8n ADDI710NAL INSUREO, the poliey�fes) muSt bB 0hdor4Btl. If SUBROGq710N IS WAIVE�,Subject lo
the terms and condlUons of the pollcy,certaln pollcl�s may repulre an endoraement A statement on thls ceRlflcate does not confer righls to!he
certlficate holder In Ilau of such endorsement s .
vRooucea Pbone:787-293-6331 coNracr
WM.F.8orhek Insurance Agency vHouE sqx
311 Plymoufh Street Fax: 787-293-2177 �ic .e:
Halltax,MA 02338 '"^u����e
Scott C Casagrande ����
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INSURERS AFIOROINGCOVEI1Ap! XAKtl
INSIIRED BeckerSPackage5tore INBURERA:Gf99IATQfiC911II13. 00.
31 Polly F�sk Lane iNeuasaa:Mass Retail Merchants
Dennisport, MA02639
INSYRbR C:
INSURER D'
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INB� E F•
COVERAGES CERTIFICATE NUMBER: ftEVI510N NU6A8ER:
7Hi5 i5 TO CERTiF7 7HAT iHE POLipES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURHD NAME�A90VE FOR THE POLiCv PERIO�
IN�ICATEO. NOTWI7HS7ANDINO ANV RE4UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE3PECT TO WHICH TH�S
CER7IFICJ�T� MAv 6E 195UED OR MAv PERTAIN, 7HE INSURP.NCE AFFORDED BY THE POCICIES �ESCRIDE� HEREIN IS SUBJECT TO ALL iHE 7ERM5,
E%CLUSIONS AND COND�TIONS OF SUCH POLIG�ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS.
IN 0. TypE�FIN3URLNCE POLIc�E�F v u r¢z
POUCY NUMBER pn L14fITe
06NERnLGABILItt EACHOCCORRENCE 3 �.����DO
A CDn�eaERCw�GENEknLUaBiUTv SPP1565778 to121f11 10121/12 , g 300,00
��dIMS•MBDE �OCCUF MED E%P(��Y��� 3 �0�0
X 6usiness Ow�ers PERS�NAL b ADV INJURV 3 �,000,00
GEVERALAGGREG4TE $ 2�000�00
GEN'LAGG0.EGATELIMITAPVLIESPE0. GROOUCTS�CONP/DGAGG 4 YrDOO,OO
X POUCY� vR0- LOC 8
nuTOMDBILE LIABI�IT/ COMBINEo SINGIE LIMIT 8
(Ee amldanp
ANY 0.UT0 -
BOOI�yINJURY(Farpm¢o�) 5
ALLOWNED4UT05 BODILYINJURY(Peramldrnp S
SCHEDULED AUTOS vRovERTY DAM4fiE
X NiFE�nUT05 (PeracWderh) 6
X NON-OWNEO>UTOS �—I g
I 3
UM6R6LtAUA6 DCCIIR EACMOCCURRENCE S
fiJ[CESS u�9 CIAIMF-MADE �GGREGRTE S
DEDVLTIBLE ?
RETENTION S
WORKERSCOMClNS�TIDN � x WCSTATU� �-0TH�
aNOfiMPLOYERB'LI0.0R�TY y�N WlT _ER__
B 4pRPROPAIETpRIPPRTNERIEI(ECUTIVE 01400�5023031 ��/01/�2 ���0���3 ELEACMACCIDENT 6 ��QiO��
OFFICERIMEMBEN E%GLUDE�9 � N�+�
�Mmtlrtwf�InNN1 U7l07/13 01l01l14 E.LDi5EA5E�EnEMGLOVEE 9 1DO�OOD
�ryee tlexraeanaer —
pE RIVTION OF OGERATION9 bBlcw El DISEASE•GOUCY LtMiY t 500���
��. PROPERTY 110,000
oEOCRIPTIoxo�ooEqAr�ous/Lourlox91v6NICtGB �qa.ehqcoRole+,Gatltnena�RemarXeseh.avl.,nmen+v.e•I.iopulna) �
3toro Location: 55 Route 23� W. Yarmouth, MA 02673
CERTIFICATE HOLDER CANCELLATION
TOWNYAR
$HOULD ANY OF THE ABOVE DESCkIBED POLICIES 6E CANCELLEO BEF02E
TOWN OF VARMOUTH TNE E1fVIRATION DATE �HEREOF, NDTiCE WILI BE DELIVERED IN
AGGOHOANCE WITH THE POLICv VROVIStoN3.
1146 MAIN STREET.RTE. 28
5.YARMOUTH„ MA 02663 AUTNORI2ECREPREBExTM1TIVE
Srott C COsagrantle
��988-2009 ACORD CORPORATION. All rights reg¢rved. �
AC01ZD 25(2009/09) Th0 ACORD namB and logo are reglstered mark9 of ACORD
11/27/2612 68: 57 17B12931360 BORHEK INS PAGE 61/62
Wm F.
d o n c�H Insurance Agency Inc.
311 Plymouth St., Hal'rfax, Massachusetts D2338—'781-293-6331
FACSIMII.E TRANSMISSION
Date: /
Please deliver this faceimile transmission to:
Company:
Recipient:
Regarding: ��,.
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FAX - (781) 293-2771
OF�Y`9�
�� `�� TOWN OF YARMOUTH
� —_ ;,� �� 1 1-�ti ROL�TE 28 SOL'TH I:�R\IOi;TH \I.�SS_-�CHL SETTS 026G-�--k�31
� MAiiqCNEES
��+ro..a..��o,b,+� Telephone ��03i 393-223L Esc 12-�I -- Fa� �;�08i 7G0-3�7?
B O A R D O F H E A L T H
November 21, 2012
Cheryl McCarren, Pres./Twilight Spirits Inc.
d/b/a Becker's Package Store
55 Route 28
West Yannouth, MA 02673
Dear Ms. McCarren,
Thank you for submitting the 2013 application for your establishmenYs retail food service and
tobacco sales licenses issued through the Health Departznent. However,prior to issuing the licenses
to you,we are required under Massachusetts State Law, Chapter 152, Section 25C, Subsection 6,to
have you demonstrate that your State Worker's Compensation Insurance is in effect and current.
The certificate of insurance copy provided with the application shows a policy expiration date of
O1/Old2.
Please have your insurance agency send us a certificate of insurance or binder showing that the
worker's compensation policy is currently in effect. Our office faa� number is 508-760-3472.
As soon as our office receives the required information regarding your worker's compensation
insurance coverage, we will be able to issue the licenses to you.
If you have any questions on the above, please feel free to contact me at the Health Department at
(508)398-2231, ext. 1241. Thank you for your anticipated cooperation.
Sincere�
Mary Alice Florio
Principal Office Assistant
/maf
cc: file
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CERTIFICATE OF LIABIL,ITY INSURANCE zo�3oiiz
Producer 7HI5 CER7IFICATE IS ISSUED AS A MATTER OF
Wm F Bwhek Insiaance Agen�y,kic. INFORMATION ONLV'AND CONFERS NO RIGHTS UPON T}1E
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Albla Bedcers Package Slwe .
55 Rwta 28 INSURER C�
Weal YartnauUi,MA 02673
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