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' � . TOWN OF YARMOUTH BOARD OF HEALTH ' =
t��� APPLICATION FOR LICENSE/PERIVIIT -'�16�� � � �
� �� . �41, , OCT c52015
'"' * Please complete form and attach all necessary documents by� r 5 2015.
Failure to do so will result in the return of your app'lication pac et. H�P..I`�? G�P T.
ESTABLISHMENTNAME: 2y�1 �QN��-y �¢,K�SPr.r�.�Ts TAxID•
LOCATIONADDRESS: /O!r `7 /2f- e2dr .So Y��`,t.�w�ryf- TEL.#: S6�r'39`/�GY�/
MAILINGADDRESS: //� 4i9TR�H��s� %2� iza�<n.� m�A O1S33
E-MAILADDRESS: ,livw� � Nc. r�c.R � �6 �+-,Ca�
OWNER NAME: (Z y aiv �.g�n��y ,g.n�s t �x c�-i-r �a�
CORPORATION NAME (IF APPLICABLE):
MANAGER'SNAME: p�T�2 C.�mFr3p« TEL.#: SaB -3�G— /9`>�
MAILING ADDRESS: /0 4 7 /2 r z � Ss.,ra YT R�•�i�
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. ?•
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitaxion (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. 2•
3. 4•
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments aze 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. Z•
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN 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 copies and maintain a file at your establishment.
l. 2.
HEIMLICH CERTIFICATIONS:
Ail 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. 2.
3, 4.
RESTAURANT SEATING: TOTAL #
OFFICE USE ONLY
-- - —._ _ _- - - - ______
t,ciu�lrvc: _ _ ------ --- _ _— _
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# L[CENSE REQUIRED FEE PERMIT#
B&B $55 CABIN $55 MOTEL $110
INN $55 CAMP $55 SWIMMING POOL$110ea
LODGE $55 TRAILERPARK $105 WHIRLPOOL $110ea
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
�0-100SEATS $125 �(6-co�{ CONTINENTAL $35 NON-PROFIT $30
>I00 SEATS $200 �COMMON VIC. $60 � _WHOLESALE $80
— —RESID.KITCHEN $80
RETAIL SERVICE: �
LICENSE REQUIRED FEE PERMIT# � LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT#
>25,000sq ft. $285 VENDING-FOOD $25 �
=<25,000 sq.ft. . $I50 —FROZEN DESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOUNT DUE _ $ ISS �OO
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
L
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
CERT. OF INSURANCE ATTACHED
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taaces and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: . /
YES " NO
MOTELS AND OTHER LODGING ESTABLISHMENTS �
TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy sha11 be
limited to the temporary and short term occupancy,ordinazily 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 aze 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 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 OPENING: '
All food service establishments must be inspected by the Health Department prior to opening. Please contact the
Health Deparhnent to schedule the inspection three (3) days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yannouth 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.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,preparation,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 I5, 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 N.
DATE: o?9 ,2U/S SIGNATURE: :
PRINT NAME& TITLE: ,' . L J O�rtil fYI//�
Rev. 10/O1/15
, �
. � � The Commonwealth ofMassachusetts
� Department oflndustrialAccidents
Offace oflnvestigations
' I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dda
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Le¢iblv
Business/OrganizationName: '�` ,9� �'/1�i�1l�y�l,lvs��+.�til� -L�
Address: /l(o CU�9 T��t��-S k ��
City/State/Zip: dur�tir /rl/�- O,iS� � Phone #: /SD8`�5� 3�110�/
Are you an employer? Check the appropriate box: Business Type(required):
1.� I am a employer with I 1� employees(full and/ 5. �Retail
or part-time).* 6. ❑ RestauranUBaz/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no y_Q Offic�and/or 1 ('n L real estate,auta,�L._
- -- - - - -
employees working for me in any capaciry.
[No workers' comp.insurance required] $• ❑ 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 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Caze
4.❑ We aze a non-profit organizarion, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.� Other
*Any applic�t that checks box#1 must aLso fill o�.the section below showing their workeis'compensakion policy infocmafion.
**If the cotpom[e officers have exempted themselves,but the corporation has other employees,a workets'compensation policy is xequ'ved and such an
organiza[ion should checkbox#l.
I am an employer that is providing workers'compensa[ion insurance for my employees. Belnw is the policy information.
InsuranceCompanyName: CA�ST�1�d�-0 �lA/�i�Tr✓cE �'6.ti�✓A`N`'�
�
Insurer's Address: 1:4.�l X �-►f �(a Sdvf� Qi�Y� s7
CiTy/State/Zip: G�ILKffS�- a��[/lC� 1P/+ /�'r/D3
Policy#or Self-ins.Lic. # �p YW CSot 3Sti 9 Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and espiration date).
Failure to secwe coverage as required under Secuon 25A of MGL c. 152 can lead to the imposiuon of criminal penalties of a
-f�:eag:s�'.,�-.,SA9:9(la�d/�r--gae ye,as-imp*+��*+**+-�nt,aswEllzs civiLgQnalties_in Yhe 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 forwazded to the Office of
Invesrigations of the DIA for insurance coverage verificarion.
I do hereby cenify, under the ains penalties ofperjury that the information provided above is true and correcK.
Si ature: � Date: /a/-� �/�
Phone#: �D8' �IS� S �1�a�/
Official 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
6.Other
Contact Person: Phone#:
www.mass.gov/dia
BERKSHIRE HATHAWAY Worker's Comoensation and Emntover's Liabilitv Policv
� � G U A R D COMPANIES EastGUARD Insurance Company - A Stock Company
Policy Number RYWC523549
Renewal of RYWC486346
NCCI No. [33936]
� Policy Information Page � � � - � - � � �-
[1)Named Insured and Mailing Address � Agency � ��
Ryan Family Amusements Inc TPA INSURANCE AGENCY INC.
126 Wa[erhouse Road . � SO NEW ENGLAND BUS CTR ' I �--� � �- � -
Boume, MA 02532-386� SUITE 303 `--- ----- �------�-
Andover, MA OL810
Agency tode: MATPAAIO
Federai Employer's ID Insured is Corporotion
Risk ID Number, 917565287
Locations on Policy - See Extension of Information Page-Schedule oi Locations
�2) Policy Period
From December 31, 2014 to Dxember 31, 2015, 12:01 AM, s[andard time at the insured's mailing
address.
[3j Coverage
A. Workers' Compensation Insurance - Part One of this policy appiles to the Workers'Compensation
Law of the following s[ates: Massachusetts,Rhode Island
B. Employer's liability Insurance - Part Two of thls polity appiies [o work in each of tbe states listed
in item [3)A. The I€mits of our tiability under Part Two are�
8odily I�jury by 0.ccident- each accident 5500,000
Bodily Injury by Disease - each emptoyee $500,000
Bodily Injury by Disease - poliry timit $500,0�0 .
C. Other States Insurance - Part Three o(this policy applies to all states, except any state fis[ed in
Item [3)A. and the states of IVorth Dakota, Ohio, Washingfon, and Wyominq.
O. This poNcy includes these endorsements and schedules:
See Extension of Informatlon Page - Schedute of Forms
[4J Premfum
The Premium Basis and, therefore, the premlum will be detertnined by aur Manual of Rules,
ClassiFlcations,Ra[es, and Rating Plans. Ali required information is subjec[to veNflcatlon and change by
audit. (Continued on another pa9e)
Total Estimated Policy Prem{um � Z�,g37
ToWI Surcfiarges/Assessments � 1,394.00
Total Estimated Cost g 24,231.00
IrarERNAL{ISE %X Page- i • Informatlon Page
MGA : RYWC523549
Date : 12/15/2014 WC OOOOOSA
MANOTE
Issuing O/flce: P.O. Box A-H, 16 S. River Street,Wilkes-Barre, PA 18703-0020 � www.guard.e6m
I � � BERKSHIRE HATHAWAY Worker's Comaensation and Emntover's L3a6iiitv aolicv
. G UARD INSURANCE EastGUARD Insurance Company - A Stock Company
COMPANIES Policy Number RYWC523549
Renewal of RYWC486346
NCCI No. [33936]
Policy Information Pa9e
Extension of Information Page
Schedule of Locations .
(L2) - 200 Main Street , Buuards Bay, MA 02532 (12/31/2014 - 12/31/2015)
(L3) 441 Main 5[reet, Hyannis, MA 02601 (12/31/2014 - 12/31/2015) �
(L4) 1067 Rte 28 , South Yarmou[h, MA 02664 (12(31/2014 - 12J31/2015)
(LS) 115 New State Hwy , Raynham, MA 02767 (12/31/2014 - 12/3112015)
(L6) 1170 Main Street, Milifs, MA 02054 (12/31/2014 - 12f31/2015)
� (L7) 999 So. Washington , North Attleboro, MA 02760 (12J31J2Di4 - 12/31/2015)
(L8) 23 Town Hall Sq. , Falmouth, MA 02540(12/31/2014- 12/31/2015)
(L9) 19 Circuft Ave , Oak Bluffs, MA 02557 (12/31/2014 - 12/31/2015)
(L10) 268 Thames St, Newport, RI 02840 (12/31/Z014 - 12/31/2015) ,
(Lil) 769 lyannough Road , Hyannis, MA 02601 (12/31J2014 - 12/31/2015)
IN�RNA�u RywC5235�y Pa9e' 2 " informatfon Page
Date : 12/15/2014 WC OOOOOlA
MANOTE
Issuing Offlce;P.O. Box A•H, 16 5. RWer Street, Wilkes-Barro, PA 18703-0020 •www.gua'd.com