HomeMy WebLinkAboutApplication and WC • r�`u�`lst:.�`csut�i�±i`S"r�2�
^" � TOWN OF YARMOUTH BOARD OF HE 'I$� �` ' :
j
' � � APPLICATION FOR LICENSE/PERIYI��'; t, ' �f�G , . . ; j
.... �^ - � W➢VI �
* Please complete form and attach all necessary docwrients��y Dece er �� , �.
Failure to do so will result in the retum of yojtr application pac --�---
ESTABLISHMENT NAME:__/auCa /st-a�re ��w�¢y �rTb-r1c`- TAX ID:
LOCATION ADDRESS: 5,�.� �u c� /c�a-,�r� Rd. TEL.#: Sa��0 8
MAILING ADDRESS: �/'�i 5i'•r2in cH�r n.r a a7�6��
OVVNER NAME: E�i�i1 .eum��/
CORPORATION NAME (IF APPLICABLE): �/E .mAacr e�/� �.v�
MANAGER'S NAME: F�ia�L KG�'drn/ TEL.#- � �o��'i�
, MAILING ADDRESS: SA�� q� ��� -
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 forni.
1. 2.
Pool operators must list a minimum of two employees cunently certified in basic water safety; standard First Aid azid
Community Caz-diopulmonary Resuscitation(CPR). Please list these employees belo�v and attach copies ofemployee
certifications to this foim. The Health Department will not use past years' rewrds. You must procide ne�v
copies and maintain a file at your place of business.
l. 2_
3. 4.
FOOD PROTECTION MANAGERS - CERTffICATIONS:
All food service establislvnents are required to have at least one full-time employee who is cenified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Seivice Establishments, 105 CMR 590.000.
Please attach copies of cei�tification to this applicatiou. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your establishment.
l. 2.
PERSON IN CHARGE:
__ _ _
Each food establishment must have at least one Person In Charee (PIC) on site durnie 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 ait tnnes. Please list your employees tranied in anti-chokuie procedures below aud
attach copies of employee certifications to this foim. The Health Department will not use past,years' records.
You must provide new copies and maintain a file at ,your p(ace of business.
1. 2,
3. 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
LODGI\G:
LICENSE REQUIRED FEE PE&'bilr# LICENSE REQUIRED FEE PER�41i� LICENSE REQUIRED FEE PER�IIT=
_B&B S55 _CABIN S55 �fOTEL S55
_INA1 S55 _C.4�Y1P 5�5 Slb'INLVIING POOL SSOea.
_LODGE 555 _IRAILERPARK 5105 �LZ-IIRLpOOL S80ea.
FOOD SER�'ICE:
LICENSE REQUIRED FEE PERMIr= LICENSE REQUIRED FEE PER\4I7= LICENSE REQUIRED FEE PERNIiT�
_0-100 SEATS S85 _CONTINENiAL 535 NON-PROFIT S30
_>100 SEATS 5160 _CObL'�fON VIC. S60 \t'�IOLESALE S80
RETAIL SER�'ICE: —RESID.KIiCHEN S80
LICENSEREQUIRED FEE PER�III'# LICENSEREQUIRED FEE PER\41T- LICENSEREQUIRED FEE PERbIIT= �
_<50 sq.8. S50 _>25,000 sq.8. 5225 VENDING-FOOD S25
�Q5,000 sq.fl. S80 (� ,3 _FROZEN DESSERT S40 �IOBACCO S55 �S
�a��E c�scE: sis AMOUNT DUE _ $ ( 3 5, p0
`"***PLEASE TIIR\OVER A\D CO�IPLE'IE OI'HER SIDE OF FOR�i'�'*"*
ADMINISTRATION = .
Under Chapter 152, Section 25C, Subsection 6,the Town ofYaimouth is now required to hold issuance or renewal
of any license or pernut to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSAT'ION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMI'. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your pernuts. PLEASE CHECK
APPROPRIATELY IF PAID: /
YES ✓ NO
R:�TELS �Ii? QTHER LL'B�GIlYf� ESTABI.�S�D4�NT'S
TRANSIENT OCCUPANCY: For purposes ofthe limitations ofMotel or Hotel use, Transient occupancy shall be
limited to the temporary and short term occupancy, ordinarily and customatily associated with motel and hotel use.
Transient occupants must have and be able to demonstrate that they maintain 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 swimming,wading and whirlpools which have been closed for the season must be inspected
by the Health Departrnent 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 area 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 establishments must be ins�ected by the Health Department prior to opening. Please contact the
Health Department to schedule the inspechon three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by Eling 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.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:
Outside cafes�i.e.,_outdoor seating with waiter/waitress service),must have prior approval&omth�Boazd ofHealth.
OUTDOOR COOHING:
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 RESPONSIBILIT'Y TO RET[JRN
THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER I5, 2010.
ALL RENOVATIONS TO ANY FOOD ESTABLISfIMENT, MOTEL OR POOL (i.e., PAINTING, NEW
EQLTIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR
TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN.
DATE: (//��/o SIGNATURE: /_�,,,r�T
T - �
PRINT NAME&TITLE: �� KI-r�I
10 06'10
' . � T!►e Commonwealth ofMassachusetts
Department of/ndustrirt!Accidents
N�felN�
600 Washington Sbeet, r"Floar
Bostoe,Mass. 0211!
Workers'Compensatioe Iroonnee AAidavlh gaildioq/Plambie�/Ekctricai Coatraetaro �
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work sih lacation ffiill add`essY
❑ I arn a homeowner par}'ormmg all work myself. Pro ect T
J YPe: ❑New Construcbon QRemodel
❑ I am a sole proprietor and have no one wodcing in any capadty. �gui�ding Addition
�. I am an employer providing workers'compensation for my employees working on this job.
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❑ [arn a sole proprietor.Srneral cortracror,or homeowner(cir�%one)and have hired the conhactas lis[ed bel�who have
the following workers'compensation polices:
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/do bereby nreify rnder h4e palws awd pewe((ta ojperfwy lhot Me lefonwylon provJle/above Lf Irue m�d m+rnct
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'ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
� iz/oi/zoio
PRODUCER 508-398-6033 FAX 508-760-1667 THIS CERTIFICA7E IS ISSUED AS A MATTER OF INFORMATION
Eastern Znsurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
1 Atlantic Ave HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
So Yarmouth MA 02664 �
Cynthia Jenks INSURERS AFFORDING COVERAGE NAIC#
INSURED We Mart Corporation Inc INSURERA: CNA
528 euck I57and Rd �NsuReae Hartford
West Yarmouth, MA 02673 iNsuRERc. �
INSIIRER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICV PERIOD INDICATED.NOTWITHSTANDING
ANV REQUIREMENT,TERM OR CONDITION OF ANY 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .
INSR DD' POLICY EFFECTNE POLICY EXPIRATON
LTR NSR NPEOF�NSURANCE POLICVNUMBER DATE MM/UD/YYYY DATE MM/DD LIMITS
GENErsa�Lwelurr 2077O73SSS OI/OSJZOIO Ol/OS/-17�7I eo.GHOGCURRENCE $ S,OOO,OO
X COMMERCIAL GENERAL LIABILITV AMA E TO RENTE
PREMISES Eaoccunence $� 1�����
CLAIMS MADE � OCCUR MED EXP(Anyone person) $ ,S�QQ
A PERSONALBADVINJURV $ j�OOO�O
. GENERALAGGREGATE $ ?�OOO�OO
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ Z�OOO�OO
X POLICV PRO- �
JECT LOC
AUTOMOBILE LIABILITY �
COMBINED SINGLE LIMIT $
ANV AUTO � (Ea a¢i0en�)
ALL OWNED AUTOS
BODILV INJURV $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILVINJURV $
NON-OWNED AUTOS (Per a¢itlent)
PROPERTYDAMFGE $
(Per accitlent)
GARAGEIJABILITY AUTOONLY-E4ACCIDENT $
ANVAUTO EAACC $
OTHERTHAN
AUTOONLV: pGG $
E%CE55/UMBRELLALIABILITY EACHOCCURRENCE $
OCCUR � CLAIMSMADE AGGREGATE $
$
OEDUCTIBLE
$
RETENTION $ $
WORKERSCOMPENSATION OSWECNK2265 �.j�Q.s�201� Ol/OS/2011 .�
AND EMPLOYERS'LIABILITY TORV LIMITS ER -
B OFFICER/MEM EREXCLUDED ECUTNEY� OSWEGVK2265 O1�OS�ZOII OI�OS�ZOIZ E.L.FACHACCIDENT $ IOO�OO
(MantlffioryinNN) E.L.DISEASE-FAEMPLOYEE $ SOO�OO
If yas,tlesaibe untler
SPECIAL PROVISIONS below EL DISEASE-POLICV LIMR $ SOO�OO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXGLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
vidence of Znsurance
CERTIFICATE HOLDER � CANCELLATION
SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TME EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL lO DAVS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAME�TO THE LEFT,BUT FAILURE TO DO SO SHALL
TOWfI of Yarmouth �MPOSENOOBLI TIONORLIABILITYOF YKINOUPONTXEINSURER,ITSAGENTSOR
Health Department REP A E5.
Rt 28 o e am
Yarmouth, MA 02664 r e n
ACORD 25(2009/07) c 1988-2009 ACORD CORPO TION. Ail rights reserved.
The ACORD name and logo are registered marks of ACORD