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Home My WebLink AboutApplication and WCil°niLsl�"�I3U v�sv i � � TOWN OF YARMOUTH BOARD OF HEALTH SEP C 2 2U15 � � APPLICATION FOR LICENSE/PE T -�0�.� H LTH DEPT. � * ?lease completa form and attach a11 necessary d��i me�t�tt3' Failure to do so will result in the return of your application packet. ESTABLISHMENTNAME: MRRInIER MOT012 �DDCs,E TAXID• � LOCATIONADDRESS:5�3 �'?�RrN S��Q�'2$'��s7Y,q,QiYaUTN��''�R-o��3 TEL.#: ri0�-3�1��$�� ' MAILINGADDRESS: - SAk� �FS L��-�'(ION ^ � E-MAILADDRESS: ma�"ineY mo-bo2'CaG(QQ � Qn�L ��on1 OWNER NAME: "��UN�S PA"f�L (PaR-rNt'�- �ro�t-�-c- CORPORATION NAME (IF APPLICABLE): MRA G,AYA?RZ M AR!-NE2 ��-C MANAGER'SNAME: `A�N�1t5 pit'fEL TEL.#: �$-'��f-��'� MAILINGADDRESS: —Ss,�l� A� /�oe.�}ztonl � �I POOL CERTIFICATIONS: i The pool supervisor must be certi�ed 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. i. �ivuSN P�ze � z. ��n�vf�vo� R�+( PflT�L Pool operators must list a minimum of two employees currently certified 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 Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. ��n�,�lg (�fF[�L 2. `91 �IKR(3�/.l YA}�e� 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 Aealth Department will not use past years'records. You must provide new copies and maintain a file at your establishment. 1. Z• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. l. 2• ALLERGEN CERTIFICATIONS: All food service establishments are 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 copies and maintain a file 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 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 Deparhnent will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# (.ICENSE REQUIRED FEE PERMIT# L�CENSE REQUIRED FEE PE;R�M'��IT(7# —B&B $55 CABIN $55 MOTEL $110 -��—�i' INN $55 CAMP $55 �SWIMMINGPOOL$tl0ea ! 09J� LODGE $55 _TRAILERPARK $105 LWHIRLPOOL $110ea. y FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# � L[CENSE REQUIRED FEE P�RMIT.# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $l25 �CONT[NENTAL $35 -#-/5 L7 NON-PROFIT $30 >100 SEATS $200 COMMON VIC. $60 WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. - $50 >25,000 sq.ft. $285 VENDING-FOOD $25 <25,000 sq.ft. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAMECHANGE: $15 AMOUNTDUE _ $ �J'ZlT•OD *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*"•** 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 Compensa6on 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 1/ N� 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 for the season must be inspected by the Health Department 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 area 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 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 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 obtatned at the Health Department,or from the Town's website at www.vannouthma.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 priar approval from the Boazd of Health. OUTDOOR COOHING: ' Outdoar cooking,prepazation,or display of any food product by a retail or food service establishxnent is prohibited. i 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 15, 2014. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW I EQUIPMENT,ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUT A SITE PLAN. DATE: . OZ 1 SIGNATURE: PRINT NAME &TITLE: �E N n�I S P PrT C_=�I G�M � Rev. 11/03/14 ��i —..,,��r,,,, i � - � The Commonwealth ofMassachusefts ^ Department of Industrial Accidents Offzce of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 � www.mass.gov/dia � Warkers' CompensaHon Insurance Affidavit: General Businesses Apulicant Information Please Print Legiblv Business/OrganizationName:MARlnf�2 ►'�oToia t��Cn'L- �'�N�R- G,Pr�f�TR1 7�'lA��ER ��C� � Address: h�3 �''��it 3`�� 2$ , Gl�c�t `�2-meu� , M A -- �28�3 City/State/Zip:G�1k yq�y,tDu��M��026�3 Phone #: �i�$ -��f ��$� �" iAre you an employer?Check the appropriate boa: 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. insw�ance required] g• ❑ Non-profit 3.❑ We are a corporarion and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have �0.� Manufacturing no employees. [No workers' comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other ' *Any applicant ihat checks box#1 must also 5ll out the section below showing their workers'compensation policy informatioa. **If the coiporate officexs have exempted themselves,but the corporation has other employees,a wockets'compensation policy is required and such an organization should check box#1. I am an employer that isproviding workers'compensation insurance for my employees. Below is the po[icy information. Insurance Company Name,7��Pj Fp(� � OL DH f3� 1'�1 U T U P5 L 'F I K E �NS U R RN C.F CD N(��I y Insurer's Address: ��2 R M C S S T�CC=T � ��'�H/�1"1 �f�l A D 20 26 City/State/Zip: ,�CDf-1PY� Policy# or Self-ins.Lic.# W � � Sg�Q � � Expiration Date: 1 l � 2 — J6 Attach a copy of the workers' compensation policy declaration page(showing the policy number and eapiration date). Failure to secure coverage as required under Seetion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civil penalties in the form of a STOP VJORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwazded to the Office of Invesrigarions of the DIA for insurance coverage verificafion. I do hereby certify,under the pains andpena[ties ofperjury that the information provided above is true and correct. Sienature: � Date: C�ID��1fI/S � Phone#: �J�� — �� O�cia[use only. Do not write in this area,to be comp[eted by city or town offaciaL City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's O�ce 6.Other Contact Persou: Phone#: www.mass.gov/dia A+ ��, �� UATE(MM/DDIYYYY) ,.., CERTIFICATE OF LIABILITY INSURANCE �,�,5 THIS CERTIFICATE IS ISSUED 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 AFFORDED BY THE POLICIES BELOW. TFqS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSWNG INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ; IMPORTAN7: If tt�e certificate holtler is an ADDITIONAL INSURED,the poliey(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condHions of the pollcy,certain policies may require an endorsement A statement on this certifiwte does not confer rights to the certificate holder in fieu of sueh endorsemen s. �'�..i. PRODUCER N�E!�T J250f1 V2f1If1Y4CC�Qf1 i, G.H.DunnlrsiranceAgency,Inc. 64 Fairha�en Ro� �y�NE . (SOB��JZAE la�c.No):�506)3223243 I POBmc497 aoun`ess: 1��9hdunn.com � Makapoisett,MA02739 INSII SAFFORqNGCOVEftpGE lWCif INsuRERA: NORFOLK&DFDHAM p3g�,5 INSURED MaaGa)etriMarinerLLC INSURERB: dba Mariner Motor Lotlge INSURER C: 573 Mtin St RIXRQ z8 INSURER D: V�st Yarrrnuth,MA OZG73 INSURER E: � INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERi1FY i}WTTF�PqJCIES OF INSURANCE L15iED BELOW HAVE BEEN ISSI�D TO iHE INSURED NAMED ABOVE FIX2 hIE POLICY PERIOD INDICA7ED. NO7WIiliSTANDING ANY�QUI�MENT, TERM q2 CONDI710N OF ANV CONiRACT OF2 OiHER DOCUIv�M WITH RESPECT TO WFYCH iWS CERTIFICAlE MAY BE ISSUED OR MAY PERTAIN, Tlf INSURANCE AFFOF2DED BY TiE PqJGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIiIONS OF SUCH POLICIES.LIMITS SI-IO�NN MAY HAVE BEEN REDUCED BY PA1D CLAIMS. ��R TVPEOFINSURANCE � POLICYNUMBER MMI�DWYYYY MM%�DD/Y� 4MITS GENERAL LIABNTY Fi�CH OCCIRRENCE $ ETOR 0 COMMERCWLGEI�ERALLWBILRV PREMISES Eaowirtence 5 CINASMPDE � OCCI.R A�ED EJ�(My one persan) S PERSOWILBADVTUf2V $ GETERFLAGGREGATE $ GENLAGGREGATELIMRAPPLIESPER: PRODUCTS-COhP/OPAGG $ POLICV PRO- �� $ AVTOMOBILE LIABIIITV COMBIf�ED SPlGLE LINOT Ea auitlent ANv AlfrO BOpLV INA,RV(Per permn) S PLLOIMJED SCFEDULED AUrOS AUTOS 90�ILYINAAiV(PeractlEenq S HREDAUTOS ��D PROPERTVDMMGE .011�OS PeraccNerrt $ $ IIMBRELLA IIAB OCCU2 EACH OCCUtRENCE $ EJICESSIIAB CLAPASM1WDE AGGREGATE $ DED REfENrION f $ (� WORKEft3COMPEN5Al10N 1/yE�S$JOM O�/ZT/ZO'I5 O�/ZTIZO'IB �STATLL OTH ANOEMPLOYERS'LIABILITV ��N PNYPROPRIERIWPARINEWEIrECUiNE ELEACHACCIDQJT $ SOO,OOO OFFlCElUMEMBER EXGLUOED't �1 N/A (MandatoryinNH) EL.DISEhSE-EAEMPLOYEE $ �,� If yes,tlescnbe untler DESCRIPTIONOFOPER4TIONSbelow EI.DISEPSE-PpLICVLIMR $ �.� OE9CRIPTON OF OPERATON51 IACAT10N91 VEHICIES(Attech ACOR0101,AtlOitional Remarka Sc�etlule,If more apaca Is requlreE� FEIN 4742G5766 CERTIFICATE HOLDER CANCELLAT�ON F�c#.(508)398-0836 SHOULD ANV OF 7HE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE TGM10fY3fR10lRh T71E EXPIRA710N DATE THEREOF, NOTCE VNLL BE DEWERED IN 1146 Rf 28 ACCORDANCE VNTH THE POLICY PROVISIONS. SaRh Yarrnouth,MA OZfifr4 wn'ow�o neae�rrrame C.. � �-- .....-..—r 7 OO 1988-2010 ACORD CORPORATION. NI rights reserved. ACORD 25(2010/OS) The ACORD name antl logo are registered marks of ACORD