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Home My WebLink AboutApplication and WC ` �a TOWN OF YARMOUTH BOARD OF HEALTH FLa = g� i� �� APPLICATION FOR LICENSElP�RMIT-?A'i�l, � * Please complete form and attach a11 necessary d�e�it��y D ' m Y�T. Failure to do so will result in the ret�n o¢your appiiGari pac e . ESTABLISHMENT NAME: - K ' T ID: - LOCATION ADDRESS: � � �E .#• � MAILING ADDRESS: E-MAIL ADDRESS: ' C OWNER NAME: �„gg.✓�� !^_ ,�jo'rr P�✓ i CORPORATION NAME (IF APPLICABLE):�' Fz ��./� /� o,q�7-r,2rA�'� . L.L � MANAGER'S NAME: �' TEL.#: _ ,?02--0 MAILING ADDRESS:�Zr�g��`L1/E�At�� ,��: nu.7 � M 14�2L.3 / 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 form. 1. 2. Pool operators must list a minimum of two employees currently cer[ified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Aealth Department will not use past years' records. You must provide new copies and maintain a file 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. �.�8 f��}C k ��=m��'� a. � PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �. Fr�� c /l �'la n, �e ,� 2. �� .�� o /,�U �,�P�4 ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one fixll-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 copies aud maintain a Tile at your establishment. t.�r� iG � .�� v 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-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 main/ta,i�n�f file at your place of business. ` 1. �a' Y�.�1 �' sc.l�aG� "J.D�i t�R<sr,.d ��r3,p...es► r� lt/..2PiS �/��'�;/720�� 3. 4. r _I2�$T�I7�1NF SfiArT-I�IG�TQT�L# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 � MOTEL $55 INN $55 CAMP $55 SWIMMINGPOOL $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 �>I00 SEATS $160 �COMMON VIC. $60 WHOLESALE $80 —RESIA KITCHEN $80 . RETAIL SERVICE: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# 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: $15 AMOUNT DUE _ $ a ao - . ****•PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***•* . � s 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. TI3E 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 !� 1 Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: ,j YES 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 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 far the season must be inspected by the Health Departsnent prior to opening. Contact the Health Department to schedule the inspection 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 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 OPEivING: 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 Yarxnouth 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 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 ofyour 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 from the Boazd of Health. 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 RESPONSIBILITY TO RETURN 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 EQUIl'MENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO � COMMENCEMENT. RENOVATIONS MAY RE A SITE PLAN. j DATE: 7�� SIGNA PRINT NAME & TITLE: Q —� �i Rev. 10/08A 3 � ' i ' � : � The Commonwealth ofMassachusetts � � Department oJindustrial Accidents Offzce oflnvestigations i ' I Congress Street, Suite I DO � Boston, MA 02I14-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legiblv i Business/Organization Name: e - i � i • Address: ��1 y�� ' �� QCUi� City/State/Zip: p� 7S� Phone #: 7 7�- '70�a 'C7lo 2g I ' 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. � RestauranUBaz/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. ' [No workers' comp. insurance required] 8• ❑ Non-profit � 3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertainment I their right of exempuon per c. 152, §1(4), and we have 10.❑ Manufacturing �i no employees. [No workers' comp. insurance required]* 11.❑ Health Caze 4.❑ We aze a non-profit organization,staffed by volunteers, i with no employees. [No workers' comp. insurance req.] 12.❑ Other •My applicant that checks box#1 must also fill out the section below showing[heir workers'compensatian policy infocmation. i **If the wtporate officers have exempted themselves,but the colporation has other employees,a workers'.compensation policy is required m�d such an organiza[ion should check box#1. � iI am as employer that is providyin7g workers'compensation insuran-c7e—jor my employees. Below is the po[icy injormation. I Insurance Company Name: /TC��-M e � '17 1.'�S r>PD Y1e,�� n7Psv i .Q i Insurer's Address: S � D 70 � � � i City/State/Zip: I i Policy#or Self-ins.Lic. # GS,` �UB "�S J� o a g`-�-r� Expuation Date: � -2 -2D��i Attac6 a copy of the workers' compensation policy declaration page(s6owing the policy number and expiration date). � Failure to secure coverage as required under Secfion 25A of MGL c. 152 can lead to the imposi6on of criminal penakies of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 Investigations of the DIA for insurance coverage verificarion. I do hereby ce nder the pains and penal8es ofperjury that the information provided above is bue and correct Si Date: 2 7 �� Phone#: 7 7 � - 7�'- 6 �-� Official use only. Do not write in this area,to be completed by city or town offaciaL City or Town: ��a�7M Permit/License# Is ' r� circle one): Board of Hea 2.Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmeds Office 6. er ContactPerson• Phone#•�Dg�98-Z231 x ��-`�1 www.mass.gov/dia � KlghtfBX Nl—Z � b/1'3/"LU14 10 : 'L3 ; 'Ly AM YAU� Z/VU'L P3X 5erver �l�� CERTIFICATE OF LIABILITY INSURANCE �ATE(MM/DDlYVYY) . T � � �TIFICATE IS ISSUE�AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS � CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDE�BYTHE POLICIES BELOW. THIS CEFTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEfWEEN THE ISSUING INSURER(S),AUTHORI2ED REPRESENTATIVE O ODUCER AND ECERTIFICATE DER. � IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsetl. It SUBROGATION IS WAIVED,subjeet to the � terms and conditions of the policy,certain policies may require and endorsemenL A statement on this certificate does not confer rights to the eertiticate holder in lieu oi such endorsement s. PRODUCER CONTACT � i NAME: i PIKE INS AC�NCY INC pHONE F.4x I P.O BO:{2743 � � � � � � � � (NC,No,Ext�: (AJC,No: EMAIL ORLEANS,M.4 02653 pooREss � � ?8GPW �� INSURER(5)AFFORDINGCOVERAGE NAICp :} �li. � INSURED �NSURER A: ACE AMERICnN INSLBANCE COMPANY CHEZFRANCKCATERINGLLC �;��Vi.'',:` :_rr��;:�;\17 INSURERB: i d �-�� __ INSURERC: � � INSURER D: : 22S GOVENOR BR.4DFORD RD INSl1RER E: 3 BREWSTER,MA 02631 INSURER F: COVERAGES CERTIFICATENUMBER: REVISIONNUMBER: I� THI515 CEATIFYTHATTHEPOLICIESOFPISUHANCELISTFDBELOWH4VEHEENISSUFDTOTHEP15UflFDNA1AE�ABDVEFDHTHEGOLICYPEFIODBJDIC4TED. NOTWITHSTANDMG MIY PEpU1FEMENT,TFAM Op CONDITION OF ANY COMFACT Oq OTHEF DOCUMENT WITH qESPECT TO WHICH THIS CEBT6ICATE MAY 6E ISSUED OF MAY PFATAPI.THE INSUHANLE AFFOHDED BYTHE POLILIES DESCFIBED HEHEIN IS SUBJECT TO ALLTHETFAMS,EXCLUSIONS AND CONDRIONS OF SUCH POLIGE3.LIMRS SHOWN MAV HAVEBEEN FFDfICF�6Y PAD CLAIMS. INSP pDD SIIB PDIJCYEFFDATE POLICYE%PDATE LTfl TYPEOFINSUFMICE L fl POLILYNUMBEF (MM�DD\VYYV) (MM�DD\YYYV) LIMRS GENERAL LIABILIN ACH OCCURRENCE $ COMMERCIAL GENERAL LI0.61LITV DAMAGETO RENTED $ CLAIMS MADE �OCCUR. REMISES(Ea occurrence) . ED EXP(Any one persan) $ ERSONAL&ADVINJURY $ GEN'LAGGREGATELIMfTAPPLIESPER: ENERALAGGREGATE �$ POLICY �PROJECT��OC PRODUCTS-COMP/OPAGG $ I AUTOM061LELJABILRY COMBINEDSWGLE $ ANV AUTO LIMIT(Ea accident) ' ALLOWNEDAUTOS BODILVIWURY $ SCHEDULEAUTOS (Perperson) HIRED AIfTOS BODILY INJURY $ NON-OWNED AUTOS (Per acciderR) PROPERTVDAMAGE $ (Px accident) 11MBRELLA LIAB OCCUR EACH OCCURRENCE $ E%CESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE g . RETENTION $ $ A WORKER'SCOMPENSATIONAND X WCSTAMOAY OTHE�9 EMPLOYER'S LIABILITY YM U3-5B6�24fi7-14 02/02@014 02/OZ@015 uldlTS ANYPROPERiTORrPARTNEWEXECUTIVE y WA E.L.EACHACCIDENT� OFFICEWMEMBEREXCWDED? � $ 1,000,000 (MandamryinNH) E.L.DISEASEEAEMPLOYEE $ 1,000,000 I�yes,tlesuibe vntler OESCRiPTIONOFOPERATioNSbalow E.L.DISEASE-POLICYLIMIT $ 7,000,000 DESCRIPTIONOFOPERATIONSlLOCAilONS/VEHICLES/RESTRICl10N5/SPEqALITEMS Ly`J��__ .-..J THCS REPLACES ANY PRIOR CERT&ICATE LSSi7ED TO THE CQ27IFiCATE HOLDER AFFECTING WORKERS COMP COVERAGE. �i.'�;I� i .� Lti�� Hrn_.�T�.� n�-r,-r. ._.: ._ CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIB ED POLICIES BE CANCELLED 1146ROUTE?S BEFORETHEEXPIRATIONDATE7HEREOF,NOliCEWILLB DELIV EO IN ACCORDANCE WI7H THE POUCY PROV AUTHORIZED REPRESENTATIVE SOUTH YARMOUTH,MA 02664 ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD 1986-2070 ACORD CORP R . rig ts reserved. . i � � VDAC 0. . - acaQroup WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 07 ( A) ' POLICYNUMBER: (6S62UB-5680246-7-74) REt�WAL OF (6562U6-5880246-7-13) INSURER: ACE AMERICAN INSURANCE COMPANY 1, NCCI CO CODE: 12165 INSURED: PRODUCER: CHE2 FRANCK CATERING LLC PIKE INS AGENCY 2NC 259 LORING AVEt�JE P.0 BOX 2743 WEST DENNIS MA 02670 ORLEANS MA 02653 I�SU�ed i3 A �IMITED �IABILITV COMPANY Other work places and IdeMiflcation numbers are shown in the schedule(s) attached. 2. The policy period is from 02-02-�4 to 02-02-15 12:01 A.M. at the insured's mailtng address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applles to the Workers Compensation Law of the state(s) Iisted here: . MA m� °— B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applles to work in each state listed in � Rem 3.A. The Iimfts of our IlabUfty under Part Two are: e= = Bodily InJury by Accident: S 1000000 Each Accident = Bodily�njury by Disease: $ 1000000 paicy LimR �= Bodily Injury by Dfsease: $ 100000o Each Employee o� m=_ C. OTHER STATES INSURANCE: Part Three of the policy applles to the states, If any, I(sted here: � COVERAGE REPLACED BY EI�ORSEMENT WC 20 03 06A m= � - D. This policy includes these endorsemerrts and schedules: �_ o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAC� o� = a. The premium for this poilcy will be determined by our Manuals of Rules, Classifications, Fiates and Rating m= Plans. Ail required informffiion is subject to veriffcation and change by audft to be made A�IALLY. FE� c s zofa DATE OFISSUE: 01-27-14 WC ST ASSIGN: MA OFFICE: ORLA�O DA ACE 24M PRODUCER: PIKE INS AGENCY INC 28�aW oiseae