HomeMy WebLinkAboutApplicaiton and WC a TOWN OF YARMOUTH BOARD OF HEALTH F ~l��i
��� APPLICATION FOR LICENSE/P$RNI��:- s � � � " d
U�._ j
" * ���'` ��� ` - _ �
Please complete form and attach all ss ece tbe �_.���
Failure to do so will result in th t i ation . ----
ESTABLISHMENT NAME: A S s �VEst- f}GH� �L v 8 Nc. T •
LOCATION ADDRESS: '7''Y Rc'77+/�`GN wA�J TEL.#:_S o8- 3 5'f� f7a/
MAII.ING ADDRESS: a oX l��' . J"'o- Y A�a�o«7�f� �vt A o'Y6 L� - o/
OWNER NAME:
CORPORATION NAME (IF APPLICABLE): ra.� �-+- �sf
MANAGER'S NAME: N'ot�rtS Ro�f Cew/rIe vo� TEL.#: o8-3%d'r'- mS�10
MAILING ADDRESS: '�'� �' '�4 S�t Sf. � �oc�� ,4R/�+ov7N Hf<1 o'r�6 s �L
POOLCERTIFICATIONS: NO �aoG�
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 form.
L 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 f'�le at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFTCATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as de£med 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 file at your establishmen�
1. �E� �luR.rpw� G2- 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge(PIC) on site during hours of operation.
1. �1CI,�ia-i� .DA't-'Z-�..� 2. �/Ii+ncEs (..X1usn�,@'�l
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. PE�� 7��/L'�bWiGZ 2. ��fkN[_E3 6�4✓S/�
3. 4.
RESTAURANT SEATING: TOTAL# � s�
OFFICE USE ONLY
LODGING:
LICENSE REQUIltED FEE PERMIT# LICEIVSE REQUIRED FEE PERMTT# LICENSE REQUIRED FEE PERMIT#
_B&B $55 _CABIN $55 _MOTEL $55
_INN $55 _CAMP $55 _SWIMMINGPOOL $SOea.
_LODGE $55 _TRAIi.ERPARK $105 _WHIRLPOOL $80ea
FOOD SERVICE:
. . . _. . . . _._ . _ . . _ _ .
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_0-100 SEATS $85 _CONTINENTAL $35 I NON-PROFIT $30 �a"�
_>]00SEATS $160 _COMMONVIC. $60 _WHOLESALE $80 �
RETAII,SERVICE: —RESID.KITCHEN $80 �
LICENSE REQUIRED FEE PERMTf# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
_<50 sq.ft. $50 _>25,000 sq.ft. $225 _VENDING-FOOD $25
_<25,000 sq.ft. $80 _FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $l5 AMOUNT DUE _ $ 3� • 60
*°'^*xPLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM****'
-1
. ;
ADMIIVISTRATION �
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 ATTACFIED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR �
CERT. OF INSURANCE ATTACHED ✓ f
OR
WORKER'S COMP. AFFIDAVTI' SIGNED AND ATTACHED �
I
Town of Yarmouth tases and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHNIENTS
1
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be i
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 demonsuate 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 i
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 Deparunent prior to opening. Contact the Health De�artment to schedule the inspection three(3)days
prior to opening.PI.EASE 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 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 I
closing. ;
FOOD SERVICE
SEASONAL FOOD SERVICE OPENIlVG:
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 Yannouth must notify the Yarmouth Health Department by 61ing 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. '
i
otrrSIDE Ca�s: �
Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior appmval from the Boazd of Health.
OUTDOOR COOKING: '
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 RESPONSIBILITI'TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIItED FEE(S)BY DECEMBER 15, 2011. �
AI.L 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 COT�IlvIENC MENT. RENOVATIONS MAY ��UIlt�ITE P N.��
DATE: � � � SIGNATURE:
PRINT NAME&T TA��s G. LEi�N-r� T�A-sli�z�
Rev.l0YL5/11 �
' � The Commonwea/th of Massachusetts
DeQartment oj/rtdustria!Accidents
M�aN�w�tllM�r
600 Waskingion Street, 7`"Floor
BosToe,Mass. 02111
Woricers'Compeesatioe I�ars�ee Aftidav&:
Pleue PR�11'kdbh
�: /iA51 RIVEI�. YAcFYI Cccag� �Nc •
�s:�-'V.��LOTJa.rlcu�W,t�, Po B�X �gv
ciry �O. rA�RM o uTH state: /VIA �o. 6'Y6Ltf ohmek SO$� �4ff' 9701 �S�AT49fi4c�
work sire t«allon truu addrcssl: J O�• 3`/S• o'Y L�' C7R�S 4'�cr/
❑ I am a homeowcer pecforming all wafc myself. O �
❑ I am a sole pro{xietor and have no one wodcing in any capacity. �b B- 3 7�' a���/��OMpf o De�)
�Q I am an b er vidin workeis'co on far m em lo workin on�is'b.3 g�-�//,r`t EG���
� , �P Y � B mP��u Y P Y� 8 J
�o�,..�: B�s �N�- y�µ, cu.o, �K�
��.: � �������.a� tiv�. �� �x i r-y
��1�, A�R-.ne4�lr IH/� � �'66�f' �a:
u.�w,s�ce. o�n s
❑ I am a sole praprietor,geaeral e�traeMr,or Yomeow�er(circ%ou�1 and have h�ied ihe cootractas Iisted below who have
the following workers compensation polices:
c000uv roe-
ad�na-
ctb• � oYaee a:
iesqa�oe ea - odkr M � .
�v noe•
ad�ear
. ei�' . . p�o�e Y'
Ineuce as oaliev N . . . .
A�e�ai�YiM��s�e�� . . . . .. .
Fdlve r sec�e aweaee o'eqiN�dv 3MIM 2SA dMC.L 132 m led b IYe A¢�tlN tQ1�YY ps�Nle da O�e y b fl,SM.M aM/�r
see ye�n'leyrchoue�t e wd n eM peuMlo 1�t�e fir�sta STO►WORK ORDBR W�me MSIM.N a day aplat ee. I ode��d Ntl•
eepy d Nh Yaiewt w�y be firwarded b Ne O�a�tla►e�ptl�r NUe DIA fr me�e vMentlw
!da hereby rnAer Me a anJpee Mo oj dry Wd Me Gfenwe�lon prev)de1 ebaae 8 eve a�d aermt
sienmuce Q'r�'�, • ��"` aa �////'✓..
�J � �" �1 �� 77G_ y�-�si 6�u-�
p��o� Le/(�r/ N �Ie.E�-,J Phone k S6 8- 3GY- �i Y� � We/QK�
.meW wy an eN n.we d th6■rn 1.ee rooWeted M cMy w e.....mcil
aily or tawa: perMUticewe N flB�YdieE peputneet
❑t4cd Hiwse�le reipemc b rtqd�ed - ���
Ps �n's Omm
. �tic�M O�O�t
�.e�e n�,o�: vr�a: i-ione
i�e s�mm�
.._..__.__...-PR0..... ._.. � ... . ....._. .. .
PO�ICY LOC S
p nvrowoei�ueaiurr : 210965 6/25/201206/25/201 .�, 1000�000
PNYAll�O . �'ORYMYUflY(MpYM) f. . . . .
RLLOWNEO SQIEWLEO BOpILYMUURY(Po�vsYEe� { �
AUf03 �AUf09
X XIREDRVt03 x �OS �� . ✓c1Ea MMA6E y
3
/� xUMBflELLAl11B X OC(:UR ' ZI.�IB�LP .SrLU��LOBII.S/ZO'I E/iCHOCL11PflENCE S�JUOOOOU
IXCESS 11A8 � CIAIMS-MPDE � A(ipPE�ATE 33 OOO OOO
DEO x PEfEMION y
. A woArcenacawexsanox 213827 01206I25201 wcstnru met
ANDEM%AYEPSWBRITY
ANTPPOPPIEfORrPAIiTfklL£%ECUtNE7�� E.LEACHACLI�EM SSOOOOO
. CFFILEPAAEMBERE%0.UOEDi O N/A
(MyneeE,alory in NX� EL DREASE�EA EMPLOVEE S$OO OOO
� OESC IP�I�ON FO OPEMTpNS Eebw EL 06EA8E�PoLIGY LIMR SSOO OOO
A P&1-Aegatta 210863 12 0B/2S/201 1,000,000
A Merine GL � � 213828 BI2S2012 0825201. 1,000,000
A LI uorLiablli 270962 8/45/20120&2Y101 1000000
� DESCflIM10NOFOPEflATIONB/LOCATqlS/VEXICLE9�AIUM�COPD1%.�CEMrnIMm�lu9e�MuhMmere�p�obnqulM)
Evitlence o1 Coverege
i
� CERTIFICATE HOLUEN CANCELLATION �
� TOWII O/Yer1110Uth SHIXIID ANY OF THE�BOVE DESCHIBED PoLICIES BE CANCELLED BEFOHE
THE IXFXATON UAIE 1HEHEOF, NOTCE WILL BE DELIVEpEO IN
. Yermouth Town Hell ACCOflDANCE WITH 1HE POIJCY PHWISIONS.
1748 Rou[e 28 .
South Vermouth,MA 02664 AVlHOPI2EUPCRIEBENf/�TIVE
� ♦
I - m 1Y88-2010 ACOPD CONPOBA710N.All ripMs reserved.
I ACORD 25(201UPo5) � o}1 T�ACOND rome entl logo ero�eplMe'ed merke of ACORD
NS5629flM15fi297 . DAH
I
I
__._. ._.-. ___�___' — — ._.._. —_'. —____
_.._ ._.... - _._. — ___ .
�
,
From: "Denece M. Herrera"<deneceh@gowrie.corru
Subject: Certiticate for Town of Yarmuth-Bass River Yacht Club
Date: July 11, 2012 9:4729 AM EDT
To: <jfleighton@capecod.neb
Cc: "Steve Prime"<Stevep@gowrie.com>
� 1 Attachment, 11.1 KB
Good Morning:
Steve gave me a call and indicated that you need the attached certificate. The policies have not been issued yet
but when they are we will update the certificate with the correct policy numbers. These are just the binder '
numbers. '
Thanks!
Denece M.Herrera .
Burgee Program Coordinator
deneceh(�aowrie.com
p:860.3993661 f:860.399.3696
Gowrie Group �
Insurence . Benefits. Finance
70 Essex Road,Westbrook,CT 06498
www.hur¢eenroeram.com
Note coverage may not be bound or altered without approval by an authorized agent and any claims reported by email wiii require an aclmowledqemeni
that the loss has been received. � �
CIIenU`:20348 BASSRIVER �
ACORD,. CERTIFICATE OF LIABILITY INSURANCE a"�"�°�`"
oimnoix
THIS CEflTIFICATE IS ISSUED AS A MATTEN OF INFORMATION ONLY ANO CONFEflS NO NIONTS UPON THE CENTIFICATE HOIDER THIS
CENTIFICATE DOES NOT AFFIflMATNEIY OFl NEGA77VELY AMEND,EXTEND OP ALTEfl THE COVERAGE AFFORDED BV THE POLICIES �
BELOW.THIS CERTFlCATE OF INSUfiANCE OOES NOTCONSTITUTE A CON7HACT BEiWEEN THE ISSUING INSUREfi(S),AUTHORIZED
REPNESEMATIVE OR PHODUCEH,AND THE CEfiTIFICATE HOLDEfl.
IMPORTANT:tt ihe eMificete holde�le an ADDITIONAL INSURED,iha polley(Iw)muat Oe e�Mwsed.M SUBFOOATION IS WANED,sub�ect to
tha terma and conEitlona ot the palicy,certaln policlos mey requlre an eMoreamerit.A efetameM on thla cenlBcate doea not w�rts r19Ms to tM
catlficate holEer In Ilau of such ontloraemaM�s�.
rx�uc� � ru : �
GowrieGroup x .860399-5945 8803993615
No:
70 Eeeex Road E+ui��: �.
Weatbfook,CT06498 ixauns nFFonoirvccrovmece xucr � .
B60 39&5945 �x�q��,Federel Inaurence Company � 20287 �
INWREO INSUPEP 9:
Basa River Vacht Club ixsunee c: �.
PO Box 182 ��.
ixsunano: �
South Yarmouth,MA 02864 '�.
INWH0IE: '�
INSUflEP F: ��
COVERAGES CEFTIFICATE NUMBER: REVISION NUMBER: '�
THIS IS TO CERTIFY T1UT THE POLICIES OF INSIIRANCE LISTEO BELOW HPVEBEENISSUED TOTHE INSURED NRMEDNBOVE FORTHE POLICYPERIOD
INDICATED. NOTWf�H5TRN01NG ANV RE�VIREMENI, TERM OR CqN�R10NOF ANY CONTRACTOR OTHEP DOCUMENr WRH RESPECT TO WH16H THIS '
CEHTIFICATE MRV BE ISSUEO OR tMY PERTAIN, THE INSURANCE NFFOROED BV THE POLIQES DESCRIBED HEfiEIN IS SU&IECT TO ALL THE TERMS, i
E%CLUSIONS�Np CONDR10N5 OF SUCH POLICIE3. LIMRS SHOWN MI1Y HFVE BEEN REp�UCED BY pP�AIOy CIAIM$.
�l q TYPEOFINSUR/.NCE � BP POUCYNIIMBFA MM'D YWDM'YEYP V�5 �
1
q c�enniu��un p�pg5p 6/2520120625✓201 epnpcMrpCoFccivanervce s1000000 � !
XCOMMHLUL�ENEMLWBRRY PPEM6E3 �rt�ence f�UOOOOU. .
ClAIMB�MApE �X OCCUR MEDf%P(An me n) $IOOOO
�asONAu Aw muUm 81 OOO OOO ,
GENERLLM3GREGATE � E2OO0000 �
f.FM �f.f.RFf.<TFII4RLCVIIFAVFR DOMIY:TA.MYONIM R2.n�.�n �