HomeMy WebLinkAboutApplication and WC � �
�' ���a TOWN OF YARMOUTH BOARD OF HEALTH ��� ��
��� APPLICATION FOR LICENSE/PERMIT -201 �`k`� � � � ;. ���� ,
� * Please complete form and attach a11 necessa�$oc�i�s�Ilece be I EPT. '
Failure to do so will result in the return of your applicahon p .
ESTABLISHMENT NAME: .. TAX ID:
LOCATION ADDRESS: �� . �' TEL.#: ,SvB"���'��66 '
MAILING ADDRESS: '
OWNERNAME: Ge�c�id .�en��� ' '
CORPORATION NAME �IF APPLICABLE): '
MANAGER'SNAME: G{,a,�id /�iaN� �r y TEL.#: �U- �S�' ���v
MAILING ADDRESS:
POOL CERTIFICATIONS: I
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.
1. 2.
Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid
and Community Cardiopulmonary 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 Department will not use past years'records.
You must provide new copies and maintain a file at your establishment. ',
1. VC�ta �� �ianni �� Z �A��S GA�drn��
�':n3:3?*LII`T C�I���GE: - _ _ __ -- — ---- -- _ _ __
Each food establishment must have at least one Person In Chazge (PTC) on site during hours of operalion.
�. G ��cd�d �� �� � �ti 2. r�oyt,� G'�r,�d� N��e
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-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 file at your place of business.
1. Z•
3. 4.
RESTAURANT SEATING: TOTAL# I�9
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
B&B $55 _CABIN $55 _MOTEL $55
I — _
_INN $55 _CAMP $55 _SWIMMING POOL $80ea.
LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $80ea
FOOD SERVICE:
� LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
0-100 SEATS $85 _CONTINENTAL $35 _NON-PROFIT $30
; I >100 SEATS $160 �1�� �COMMON VIC. $60 I 'OZZ _WHOLESALE $80 .
RE7'AIL SERVICE: —RESID.KITCHEN $80 �..
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ��
_<50 sq.R. $50 >25,000 sq.ft. $225 _VENDING-FOOD $25
_<25,000 sq.ft. $80 —FROZEN DESSERT $40 _TOBACCO $95
NAME CHANGE: $15 AMOUNT DUE _ $ 2 ZO .O6
I
**•*•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
I
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ADMINISTRATION
Under Chapter 152, Section 25C, Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
j of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
C Compensation 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 ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES .� NO
MO'f'-�I.S A�IA OTHER LODGING ESTABLISHMENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel 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 shall generally refer to wntinuous occupancy of not more than thirly(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 ar
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 II
by the Health Department prior to opening. Contact the Health De�artment to schedule the inspection three(3)days
prior to opening. PLEASE NOTE:People are NOT allowed to srt 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 standard plate count
by a State certified lab, and submitted to the Heaith Department three (3) days prior to opening, and quarterly
thereafter.
.-- _
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered witlun 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 Department by filing the
required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be
obtamed at the Health Department,or from the Town's website at www.varmouth.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 �
OUTSIDE CAFES: (
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OUTDOOR COOHING: �
Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited.
NOTICE:Pernuts run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY 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 COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN
DATE: I I � I�' � *� SIGNATURE: �,/ J w�.o.,--(
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PRINT NAME& TITLE:_ �' eRdl t� r/i¢�]�in��ierS�dr+7�jL1h� a/t/�- I
Rev. 10/09/12 '��
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� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office oflnvestigations
i 1 Congress Street,Suite 100
j Boston,MA 02114-2017
www.mass.gov/dia
�I Workers' Compensation Insurance Affidavits General Businesses
Anplicant Information Please Print Leeiblv
Business/Organization Name: Ct�illl P�(AI'S PUb,IIIC. _ __
668 Rk�Main St
Address: m�.v._.�..� u��
�
City/State/Zip: Phone#: ��� �� �� � a �'�'
Are you an employer?Check the appropriate box: Busi�ess Type(requiredj:
1.❑ I am a employer with employees(full and/ 5. � Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishmern
2.❑ I am a sole proprietor or paztnership and have no 7, � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance requ'ued� 8• ❑Non-profit
3.❑ We 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]* I1.❑$ealth Caze
4.❑ We aze a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑Other
*Any applicant tha[checks boz#1 must also fill out the section below showing[heir workers'wmpensation policy infotmation.
'•If[he coryora[e officers have exempted themselves,but the corporation has other employees,a workers'compensa[ion policy is required and such an
organization should check box#1. . .
I am an employer that is pravfddng workers'compensation insurance jor my employees. Below is the policy injormabon.
Insurance Company Name:
Insurer's Address:
CiTy/State/Zip:
_ Folicy��r Seif-hrs:t,i�: rt�--- -___-- __---------- �pxatien-Batc
Attach a copy of the workers' compensation policy declaratiou page(showing the policy number and expiration date).
Failure to secure coverage as requ'ued under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-yeaz imprisonmem,as well as civil penalties in the form of a STOP WORK ORDER and a Sne
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwuded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify,under th ains and penal[i s of perjury that the rnformauon provided above is true and correct.
Si ature: 1CJ/�✓�'"" Date• II'l�"/a'
Phone#: �tiP ' 79I ' ��66 S`�S - 36y- �7vd
Officia/use only. Do not write tn this area,to be completed by city or town o�cial
City or Town: �H.r2,/ND�)�bl- Permit/License#
Iss ' ' (circle one):
.Bo rd of Health . Building Department 3.CiTy/Town Clerk 4.Licensing Board 5.Selectmen's Office
Contact Person: Phone#: �DR-�i9A��3�X��2�//
www.mass.gov/dia � .. . .. . . . . .
' 9�'�'�V , ,. CCR I'iFICATE O� LIABILITY INSURANCE �`T`'�������""'"'
' 11/i9/zoiz
THIS CEPTIFICATE IS 19SUED A9 p MATTER OF INFORMAT�ON ONLY qND CONFERS NO RIGHT9 UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFF�RMATNELV OR NEGATIVELY AMEND, EXTEND OR ALTER TFIE COVERAGk AFFORDED BY THE POLICIES
BELOW. TH�S CERTIFICpT� OF IN9URANCE DOE9 NOT LON$TITUTE A CONTRACT BETWEEN THE I$SUING' INSURER(S), AUTHORIZED
REARE9ENTA7IVE OR PRODUCER, AND THE CERTIFlCATE HOLDER. .
IMPORTANT: If the cenlficate holder Is an ADDITIONAL INSURED,the policy(les)muet be entlorsed. If SIJBROGATION IS WqIVED,subjeM co
ihe tefms and pontlftbna oi(he policy,certeln polielpy may require en ondoreement A stakmunl on thie certlfltata Coes pot confer hghts to the
Certifrcate holtler in lieu o(sucM1 endoroemenl(s),
RODUGER A T
MCSHEA INSURANCE AGENCY INC "'°mE:
PMONOE � �SOS��IYO�9O�.�. uCNo:�508)420-9010
1550 Falmouth Rd Ste #2 E-
Canterville, MA 02632 nooRes :chevonne@mcsheainsurance.com
. N'BYREqrJ� p�OH01NQ ('QyEqqOE NpICtl
� I '� �il ���'s D; NSURERn:NatlOnal Grange Mutual Ins Co.
usuRe� Captain Parkers Pub IiiC. M1 Atlantic Charter Insuranee Co.
NSURER B:
, � � � 'i'�J. NSURERc: '
668 Main Street �'�'� � `' `��
SURER D:
W. Yarmouth, Ma 026 HEALTHDEPT. suReRe:
506-771-4266 iwsuRert F:
%OV�RAGES CERTIfICATE NUMBER; REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTE�BELOW FfqVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
. INDICATEO. NOTN/ITHSTANDING A�JY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR O7HER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MqY BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFOROED BY THE POLICIES DESCR�BED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONbITONS OF SUCM POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS.
aoo� e
iA TYPE OF In3URpN�E iNap POIICY NUMBER �OOM1'Y MMlDDY� LIb71iS
CaENERFL LIABILITY . EACH OLCVRRENCE $ Z OOO OOO
X COMMERCIHLGENERALL�ABILIN PREMI8E6 Eae�tnnan�¢ S ,rjQO ��0
CIAIM6-A7qDE �X OCCUR '� MEDEXP(MyqieOercon) E jQ OQ�
�'' HPT2388U 9/5/2011 4/5/2012 pER50NAL8pOVINJURV S 2�OQ0���0
9/5/2012 q/5/2013 GENERn� nccaeGATE 5 4�000,000
GEN'l AGGREGATE LIMR APPUES PER: PftODUCTS-COMP/OP AGG 5 A�OOO OOO
X POLICY PR4 , �
T' LOC 5
AUTOMOBILE LIPBIIITY E LIM
EaecUtlenl ���0���00
�A�O 6/25/2011 9/25/y012 BODI�YINJURY�Perpc-aan) 5
�.�OWNED S�HEDULED MZIBSS�IZ
A �+UTOS qUT03 90DILYINJURI'(PefecGtlml) S
HINEOGUTOS p�pSWNEO 4/25/2012 4/25/2013 PR�P E
Per eceltlenf t
S
UMBRELIA LwB X OCCUR
A Faccess ��ne BPT2388U 9/5/20i1 4/5/2012 EACH OCCURfiENCE s 2,000,000
CLqM13t�MOE LIQUOR LIAB 4/5/2012 4/5/2013 AGGREGFTE g 4 �00 ��Q�
OE� RETENi101J$ s '
WORKERS COMPENSATION WCSTMTU- OTH-
AND EMGLOYENS'LIIIBILITT y�a YLIMITS
B O cewNE B R�EI(C UDEG�E���� � �+/a E.L.EACHpCqOENT 5 SOO OOO
��dYM�lsryinNM1 FaWC3037092 ./1/zo12 4/1/2013 E.L.UISEASE-EA�MP�pVE s 500,000
��yas.tlaxrloe unaer
OESCRIPTIONOFOPEMTIONSbelow E.L.O�SEASE-POLICYLIMR S SOO OOO
A tR4BRELLA #CUT2388U oa/osizoii oa/os/zoiz 1,000,000
01/OS/2012 Oa/OS/2013
�ESCR�PT�ON OF OPERATIONS/LOCAT�ONS/VEHICLES (AI(ach ACpRO 101,AGClllawl Remarb Sdwtlula,If mole epaee ie required) �
;ERTIFICATE HOLDER CANCELLATION
TOAtri Of Yarmouth SHOULD ANY OF THE ABOVE DESCRIBED BE CANCELLED BEFORE
5083980836 THE EXPIRATION DATE THEREOf, OTICE WI BE DELIVEREO IN
ACCORDA �WITH THE POLICY PROV SIONS.
• AUT 6U REPRE A�
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