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Home My WebLink AboutApplication and WC� , . � - - � '�t�.P ��, � � TOWN OF YARMOUTH BOARD OF E�fi`I'�I" � APPLICATION FOR LICENSE�/,� �3�014 <�� NOV 1 8 2013 * Please complete form and attach all neces cuments by ece Failure to do so will result in the re qf your applicari ESTABLISHMENTNAME: • LOCATION ADDRESS: a �� TEL.#: MAILING ADDRESS: E-MAII,ADDRESS: W� =�yH-fn.�� ti Co�*Last • r1�� OWNER NAME: CORPORATION NAME (IF APPLICABLE): • MANAGER'S NAME: 121 Y Tqpy�pr T�� TEL.#: So l' �f o�'G G MAILING ADDRESS: Sn�rth Yn��. POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator,as required by State law. Please lisYthe designated Pool Operator(s) and attach a copy of the certification to tlus form. 1. 2. Pool operators must list a minimum of two employees currently certified in basic water safety,standard First Aid and Community Cazdiopulmonary Resuscita6on(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this foim. The Health Department will not use past years' records. You must provide new copies and maintain a fle at your place of business. l. 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 Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ICo y�dc. G�+ad�:,�K- - ,3A1 Z �n w,�c �j�r�d,��.z - K,•r�t�.., , AY,LERGEN CERTIFICATIONS: All food service establishments aze required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copi�s and maintain a Tile at your establishment. 1. 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich euver on the premises at all times. Please list your employees trained in anti-chokmg 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 £ile at your place of business. L ( 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQU(RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&.B $55 CABIN $55 MOTEL $55 �NN $55 CAMP $55 SWIMMINGPOOL $80ea LODGE $55 TRAILERPARK 5105 _WHIRLPOOL $SOea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT tt LICENSE REQU[RED FEE PERM[T# LICENSE REQUIRED FEE PERMIT k 0-100 SEATS $85 CONTINENTAL $35 NON-PROFIT $30 1 >100 SEATS $160 �� 1 COMMON VIC. $60. � _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: L[CENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��. <50sq ft. $50 >25,000 sq.ft. $225 VENDING-FOOD S25 <25,000 sq.ft $80. �ROZEN DESSERT $40 � _TOBACCO $95 NAME CHANGE: $15 AMOiJNT DUE _ $ 22.0.OD •••*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM•`*** \ i 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 WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR iNi! �y�p;,;-, _, h2 ntiM$C'.?�i CERT. OFINS�J��.�'��D i WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED , :it:;:��:e��l +. . - � Town of Yarmouth taxes and liens musf�be`paid pYio� to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: x:c�' •" YE5 NO MOTELS AND OTHER LODGING ESTABLISHMENTS � TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall 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 sha11 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 Deparhnent prior to opening. Contact the Health Department to schedule the inspecHon three (3) days ` prior to opening.PLEASE NOTE: People are NOT allowed to sit in 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 ope�ing, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained ar 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 priar to opening. CATERING POLICY: ( Anyone who caters within the Town of Yarmouth must notify the Yannouth 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.yarmouth.ma.us under Health Department, Downloadable � Forms. i FROZEN DESSERTS: I� 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 OUTSIDE CAFES: � Outside cafes(i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. f OUTDOOR COOHING: � Outdoor cooking,prepazation, or display of any food product by a retail or food service establishment is prohibited. , _. -_ . - — - - - - -- _. _ ---_ _—_ _ _ ___ _.__ _ ___ � NOTICE: Pernuts run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN I THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 13, 2013. � ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.),MUST BE REPORTED TO AND APPROVED BY THE BO RD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE ITE PLA . � DATE: SIGNATURE: � PRINTNAME&TITLE: l��alc� /�An, �., �iQ.t.c�r,I � Rev. 10/08/13 � '�, ' The Commonwealth ofMassachusetts 9 , � Department oflndustrial Accidents Office oflnvestigations ' I Congress Street, Suite l00 Boston, MA 02114-2017 www.ma,rs.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information � Please Print Leeiblv Business/Organization Name: , Address: ��'��' WestY , City/State/Zip: Phone#: Are you an employer? Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. �RestaurantBaz/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, Office and/or Sales incl. real estate auto etc. � , employees working for me in any capacity. � � � 3.�Wo workers' comp. insurance required] 8• ❑ Non-profit e aze a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We aze a non-profit organizaUon, staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.❑ Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy iaformation. *'If the colpo�ate officers have exempted ihemselves,but the corporation has otLer emp(oyees,a workets'compensazion policy is required and such an �� organization should check box#1. � � � � I am an emp[oyer that is providing workers'compensation insurance jor my employees. Below is the po[icy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic. # Expiration Date: Attach a copy of the workers' compensaHon policy declaration page(showing the policy number and eapiraHon date). Failure to secure coverage as required under Section�SA of MGL a 152 can lead to the imposition of criminal penalties of a j fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine j of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of j Invesfigations of the DIA for inswance coverage verification. ; I do hereby certify,under the pains and naUies of perjury that the injormation provided above is true and correct i i � Si ature: Date: 1- / �"/3 Phone#: � � �7 �" oZ � G Officia!use only. Do not write in this area,to be completed by city or town officiaL City or Town: �/A,QhW�rt Permit/License# Iss�u' �A� c�rcle one): L' oard of Hea 2. Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmeds Office 6. Other ContactPerson: Phone#: Stl$-398-2Z3I xl2yl www.mass.gov/dia Nov. 18. 2013— 4: 03P No. 8710—P. 2 ��TM CERTIFICATE OF LIABILITY INSURANCE �A�"�"��"Y'�� 2 1 Pnoouceq � ni1S CER71FICaTE IS ISSUED AS A MATTER OF INFORMATION MCSHEA INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES N07 AMEND, EXTENU OR 1550 FalIDouth Rd Ste #2 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Centerville, 2dA 02632 508 420-9011 INSURERS AFFORDING COVERAGE NAICI! INSURED Captain Parkers Pub, IIIC. �NSURERp: NdClOftdl Gran e 668 Main Street INSURER 9: H r f r ce W. Yarmouth , Ma 02673 u+suaeRcr 506-�71-9266 �NSURER D: INSUNER E: COVERAGES THE POLICIES OF INSURANCE LISTEO BELOW HA�BEEN�SSUEO TO TH�INSUR�D(JqA�ED ABpVE FOR THE POLICY PERIOD INDICNI'ED.NOTWITHSTAND�NG ANY REQUIREMENT, TEqM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NIHICH THIS CERTIFICA7E MA�'BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJEGT TO ALL THE TERMS,EXCLUSIDNS AND CONORIONS OF SUCH VOLICIfS.AGGRE W?E LIMITS SHO WN MHY HAvfl BEEN REDUCED BY PAID CL41MS. meR ov4 ' POLICYEFFECTVE P LI YE%PIMTI N iTh NSND T'V FIN GOLICYNUM9E0. pA7EM11h11pD nnreran�mom IIMITS GENERAL LU�BILM EACH OCCURRENCE 3 1 OOO OOO ][ (',pMMERCWGENERpIIIAB�4T" PREMISES Eeocc�tlMce s ZOO OOO CLFIMSMNDE QOCCVR MEDERV(Myoreperaon) S S OOO A BPT2388U 4/5/2013 4�5�201� PEflSONNLBADVINlURY 5 1 kiauor L18t1. GENERp4 AGGRE�+ATE s 2 000 000 GEN'LqGGREGpTELIMITNPGLIESPER: PRODUCTS-COMPIOPAGG 5 2 QOO OOO POUCY P LOC AUTOMOBILE IIABNN COMBINED S�NGLE LIMiT ANYAUTb 1 ,Is�r uR�7 r GT� (EaecdUenq f w�� L5 \J LJ ALLOWNE�AUTOS BOOIIYINJURY SCNEDULEDnUT05 NOV 19�20 3 (Perpneen) S HIRED AUTOS BODILYINJURY 5 NON-OWNEDnUT05 H�TH DE . �� PROPERTY DPMAGE a (Peracpid��) GqRP.GELInBILRV AUTOONLY-E�ACCIDEM 3 ANYnUTO O7HERTHnN FJ��+CC s AU�OONLV: qGG T EXCESSNMBRE�I,qLIqBILIIY FALHOLCURRENCE S 1 OOO OOO pCCUR �CLAIMSMADE AGGREONTE S 1 OOO OOO CUT2388U 4/5/2013 4/5/2019 = OEOUC71gLE E RE7ENTIQN 5 S WORKERSCOM1IPENSATIONAND V IMI Eµ EMPLOYERS'LIABILITV 08GTECCM3443 9/1/13 4�1�14 E.LEACNACCIOENT E $�� P�'11'PPOPqIETO1�RnliTtffFIEIECVIIVE 8 OFFICERIMEMBEROICLUDEM E.L.OISEASE•EAEMPLOYE S SOO OOO IIyee,0exrloe�nax $PECMLPROVIS�ONSbNow E.L019EASE�POLICYLIMYf S �JOO OOO OTHER DESCRIPTION OF OPERATIONS/LOCNTION9!VEHICLE6I E7lCLUSIONB ADDED BY ENDORSEMENrI SVECULL PROVISIONS CERTIFICATE MOLDER CANCELLATION SHOVLD ANY OF TNE 4BOVE DESCRIBED 70lICIE3 BE CANGE�LED BEFORE iXE ExPIRNTION TOVlIl Of Y8T1{IOl1tY1 DATE THEREOF,THE ISSUING INSURER W�LI fiNOEAVpR TO MPILl� DA�S �^1RmEN Buiiding DeparYment NOTICE TO�HE CERTIiICATE HOLDER NMAED TO 7HE LEFf,B17�FAILUAE TO DO 50 SHALL Yarmouth, MA IMPOSE NO 09LIGA7ION OR LWBILIN OF IWY KIND UPON iHE INSURER, RS AGEMS OR REPRESENTATNES. AViHORI D RESGNT�TNE �1 n COYn]��J ACORD 26(2001108)' �ACORD CORPORATION 1988