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TOWN OF YARMOUTH BOARD OF HEALTH U �� ;
� � APPLICATION FOR LICENSE/PERM��'�20 6 (� 9
* Please complete form and attach all necessary�� � y b e �I"� ��S.U15
' Failure to do so will result in the return��o`itr�a}3pl�c ti7br� , ��AL?H DEPT.
6 _. c,� ��` i
ESTABLISHMENT NAME: a o..t oro..G .ll TAX ID:
LOCATION ADDRESS: ..�n u� a--�' TEL.#: S�d° -Z 21.�
MAILING ADDRESS: �i' ,�-- �rt Sf�-/'
E-MAIL ADDRESS: Nl/) -
OWNERNAME: Q Po$�ot� � ���-�?'�l1�
CORPORATION NAME (IF APPLICABLE): 1A • I� `1�i 2 I��lGx�
MANAGER'S NAME: �li�09�`�a�S� � TEL.#: S�P- � 2-18�
MAILING ADDRESS: � o $9 r� �y 2 t1 4or��i�3i o-� �j.Q O�'G 3 3
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operatar(s) and attach a copy of the certification to this form.
�---1. - --- _ g,
Pool operators must list a minimum of two employees currently certified in standazd 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 cerhfications 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. �Q�^T o Lv�7 �tif�%N4 �J 2, �.�t�✓IS'`, " �1.7(�6�es2v/'�
, 3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishxnents 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 DepaMment will not use past years' records.
You must provide new copies and maintain a file at your establishment.
1. 'P�6�^COI.o g �(.-�/v✓`� 2 �(�i���' V �`� ll/I.l v(�/I�
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hoars of operation.
1. ����O�JQi '�J1iJ'�0�`09 2.
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 and maintain a file at your establishment.
1. �Q��OLo9-i �L19TJo� 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 Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. ���S��oLoS� ��oL�v��� 2.
3. 4.
RESTAURANT SEATING: TOTAL# 9/,r�
OFFICE USE QNLY___—___ _-- --- -
--�-u..-i�c:—---------
__ _ _
---._ .
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQU[RED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $1l0
INN $55 CAMP $55 SWIMMINGPOOL$IlOea.
LODGE $55 TRAILER PARK $105 WHIRLPOOL $l IOea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100 SEATS $125 �W� CONTINENTAL $35 NON-PROFIT $30
>l00 SEATS $200 �COMMON VIC. $60 �� =RE�D. KITCHEN $80
RETAILSERVICE: �
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
<50 sq.ft. $50 � >25,000 sq.ft. $285 VENDMG-FOOD $25
=<25,000 sq.ft. $150 _FROZEN DESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNTDUE _ $ I8S.O0
*****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
Compensation Insurance. THE ATTACHED STATE WORKER'S COM ENSATION 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 pri r to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID:
YES NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes ofthe 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 Deparhnent by filing the
required Temparary 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.
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 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 3 L IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2015.
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 PLA
DATE:,o�jj�,/�,f SIGNATURE: ��` �
PRINT NAME & TITLE: � v�' /��
Rev. 10/O1/15
, , , ; � The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
' I Congress Street, Suite 100
Boston, MA 02II4-20U
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: Q JYf1L L� f�gT AJ R+9� � �!'�7jc
Address: �> /��,:n �N�- Y�r+-w,.�+ �o�� ✓yl.�oZ6 aS
City/State/Zip: �o✓�.-r�a„� �� � Phone#: S� 3�o�s ��9
Are you an employer? Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑ Retail
�_ _ _ _ _ or Qart-time).* 6.�RestaurantBaz/Eating Establishment
- —
2.�] I am a sole proprietor or partnership and have no �, � 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 are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemprion per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4. ❑ We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
*Any applicant that checks box#1 must also fill oac the section below showing their workers'compensation policy infoimation.
i •*If the corpomte officers have exempted themselves,but the corporation has other employees,a workers'compeasation policy is required md such an
'� organization should checkbox#1.
I am an employer that is providing workers' mpensation insurance for my employees. Below is the policy information.
Insurance Company Name: (9��i�� �A S 4✓'0...zt e �ov.��
Insurer's Address: 0= � �q� �-/"f i�/� S. ��v't.✓� �� �,vi1 kPJS-�gpvr �L �4
--�
City/State/ZiP: �{��G�¢i- ^ �6� ✓Y�'� � �`��a 3 " O� 2�0
Policy#or Self-ins.Lic.# � �J ��i �8 p Jr.T� Expiration Date: �/��/ /�
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and ezpiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalries of a
�ine np to$i,3DGG�an�tor one year3mgrisatunent;as welt as oivi3 pex:a.'ties in�€arm ofa ST-0P�-0R�4 OFtDER-a.nd-a�in�
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify, nder thg pa'zns and penal ' fperjury thal the information provided above is tru,e/and correct.
Si ature: ����""� Date: �� �( � �-
Phone#: r��[, � �` ' -�!CJ J�
Officia[use only. Do not write in this area,to be completed by city or town offuiaL
City or Town: Permit/License#
Issuing Authority(circle one):
; 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
I 6.Other
Contact Person: Phone#:
� www.mass.gov/dia
NOTICE � NOTICE
TO , � TO
EMPLOYEES � EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, �uite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma,us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this wiil give you notice
that I (we)have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
Nor6UARD Insurance Company
NAME OF INSURANCE COMPANY
P.O, Box A-H, 16 S. River Street, Wilkes-Barce, PA 38703-0020
� ADDRESS OF INSURANCE COMPANY
ABWC688559 03/18/2015 03/18/2016
POLICYNUMBER 973 Iyannough Road P.O. Box 1990 EFFECTIVEDATES
DOW UNG&0'NEIL INSURANCE � Hyannls, MA 02601 508-775-1620
NAME OF INSURANCE AGENT ADDRESS PHONE#
A.B. Pizza II Inc 715 RTE 6A Yarmouthport, MA 02675
EMPLOYER ADDRESS
02/25/2015
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANl� DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical servi ces in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Repon of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonabie cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is n�essary and
reasonably connected to the work related injury, ln cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL �D�SS
TO BE POSTED BY EMPLOYER
` � Y
ACORD,� EVIDENCE OF COMMERCIAL PROPERTY INSURANCE '"�`M�"
04/0B/2075
TIMS HVIDENCE OF COMMERCUIL PROPERTY INSURANCE IS ISSUED AS A MAT7ER OF INFORMAl10N ONLY I1ND CONFERS NO RIONTS UPON
TNE ADUIiIONAL IN7EREST NAMED BELOW.THIB EVIDENCE OF COMMERCIAL PROPERTY INSURANCE DOES NOT AMEND,EXIEND OR
PRODUClRW1ME�CONTACT p� No x11:5OH77S-'IB2O COMPANVlUMEANDRDDRlBS MAw'M�:
rensoxµonooResa �- --- LbydsofLondon
DovAing&O'Nell
Insurance f�enq Hyennis ,MA 02801
973 lyannaugh Rd., PO Box 1990
Hyannls,MA 02801
f� .SOBT/B'IY�S IF MULTPLE COMPANIE9,COMPLETE SEPRMTE FORM FOR PACN
�ppE: SUB CODE: POLICY TYPE
. ��
NNMEDINBUREDIINDAODR6$t LORNNUMBER POIICYNUM�R
A.B.Plua,Inc.DBA Royal Pizza XSZ47489
P.O.Bwt 1424
Dennit�t,MA 02839 EFFECTIVE DATE 6%P�MiION DATE �iNUED UMIL
01IOBI201$ 01/OB/ZO16 TERMINATEDIFCHECKED
RDdTqN�L W1MED RqURlW81 Tf18 REVIACEB WtlOR EtlIDENC!UA�FO:
PROPERTY INFORMATON Use REMARKS on P e 2 H more s ee ie uired � BUI�oiNO oR ❑ 9US�NESS PERSONNL PROPERTY
LOCA7IOW0l8CPoP710N
Location 9:1 374 Lowe�Counly Road D¢OOISDOrt,MA 02639
Bulltling S:t Seasonel Famtly Slyle Plua ReetauraM
THE POUCIES OF INSUMNCE USTED BEIAW HAVE BEEN 198UED TO THE INSURED NAMED ABOVE FOR TME POLICY PERIOD INDICATED.NOi1M7HSTANDING
ANY RRAUIREMEM,TERY OR CONqTON OF ANY CONTRACT OR OTHER DOCUMEN7 WITN RESPECT TO WNICN T1i18 EVIDENCE OF PROPERT`/IN8URANCE MAY
BE ISSUED OR IMY PERTAIN,7HE INBURANCE AFFORDED BY 7HE POLICIES DE9CRIBED NEREIN IS 8UBJECT TO AlL TFIE TERMS,EXCIU&ONS AND CONDIilONB
OF SUCH POLICIES.LIMITS BMOWN MAY HAVE BEEN REDUCED BY PAID CUIMB.
� COVERAOEINPORMATON PERIl51NSUBED ensic eaono X saeciu
COMMERCIAL PROPERTY COVERAGE AMOUN7 OF INSURANCE: {5pp�p0 BUlltlln DED: $��ppp
NO Wl1
❑ BUSINESS INCOME ❑REN7AL VALUE M VES,LIMIT: Actud Lou SuqMnW;#d moMhm
BLANKET COVERAGE X 11 YES,iMicate value(s)repate0 on propMy ItleMMed above:9
� TERRORISM COVERAGE Atlach Diadoeuro Ndice/DEC
� ISTHEREA7ERRORISMSPEGFICEXCWSION?
IS DOMESTIC TERRORISM EXCLUDED?
LIMITED FUNOU3 COVERAGE It YES,LIMIT: DED:
FUNOUS EXCLUSION pF"YES",apedN wpanlzation's loim usetl)
REPLACEMENTCOST X
AQREED VALUE X
COINSURANCE X IfYea,80 % Bullding
E�UIPMENT BREAIfDONM(If Apd��s) M YES.LIMIT: DE�:
� ORDINANCE OR LAW -Covaraps for bse to untlamapetl poMon M dGg
•Demdkbn Costs II YES,LIMIT: _ DED:
-InU.CAet Dt CwialNqlOn 11 YE3,LIMIT: DED:
EARTFI MOVEMEM(M Appltrade) If YES,LIM�T: _ _ DED:
FLOOD(RAppIlcaMe) HVES,LIMIT: _ DED:
WINDMAIL Qf Subjecl to DHferoM Provleions) If VES,UMIT: DED:
PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MOR7GAGE
HOLDER PRIOR TO L083
CANCELLATON 7 D tr
8HOULD AMY OF 7HE ABOVE DEBCFGBED PO4CIES BE CANCELLED BEFORE TNE E%MRA710N DATE THEREOF,THE 199UIN0 INSURER VYILL ENDEAVOR TO
MAIL� DRYS WRIT�EN NOTICE TO THE ADdTONAL INTEREST NAMED BELOW,BUT PAILURE TO IAAIL SUCN NOTICE SHALL IMPOSE NO OBlI0A710N
OR LIABILI7Y OF ANY qND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
ADDITONAL INTEREST
X MORTGAGEE CAMRAGTOFSALE' LENDERSERVICINOROENTN�MEFNDl10DRE88
lENOERSlOSSPAYABLE
NNMEANDADORlSE -' - "" "-
Cepe Cotl Five Cenla SaNngs Bank,
ISAOA,ATIMA
P.O.Bm�5241
Nohvell,MA 02061
RUTHOARED lSENTNTIYS
�-�-�'R �'-=_-°=�.,
ACORD 28(200&07) S 4278 Page 1 of 2 O ACORD CORPORATION 2005•2008. NI rlghts reservsd.
The ACORD name and logo are regislered marka of ACORD LS7
EVIDENCE OF COMMERCIAL PROPERTY INSURANCE REMARKS-Including Special Condklo�ro(Use only if more epace k requirod)
""Commercial Property Location Specific Coverages'••
AmouM of Insurance:500,000
Subjed of Insurence:Building
Valuation:Replacement Cost Agreed Amount: No
Deductlble: $1,000
Subject of Insurence:Wind Coverage
Limit: DeducKible:$10,000
Subject of Insurance: Building Ordinance or Law-Combined A, B&C
Limit 60.000
Subject of Insurance:Badcup of Sewers 8 Dreins Coverage
Limit:25,000
Amount of Insurance: 100,000
SubJect of Insuranc�e: Business Personal Property
Valuatlon: Replacement Cost Agreed Amount: No
Replacement Cost:Yes
Coinauren�:80^k
Cause of Loss:Speaal(Including Theft)
Daductible: $1,000
Subject of Insurance:Wind Coverage
Limit: Deductible:$10,000
Amount of Insurance: 180,000
Subject of Insurance: Business Income With Extra Expense
Valuatlon:Actual Loss Sustained Agreed Amount: No
Limit: 180,000
Coinsuranrs:80%
Ceuse of Loss: Special(InGuding Theft)
Deductible: $
ACORD 28(2006/0» Qo/ 2 S 4278 LS1