The URL can be used to link to this page

Home My WebLink AboutApplication and WC �.�.'e�'�l�i'�`�'�AF7�S j � �* �� TOWN OF YARMOUTH BOARD OF HEALTH � ��-�- - - I I APPLICATION FOR LICENSE/PERM T,-2 16 �Q� O Z U 1 5 ` ""°' ��e��-D � ' * Please complete form and attach all necessary;�lo ., t by e mber 1 S 015. ; ' Failure to do so will result in the return pf yQiir,a,�plicat�on `acl�� F�,_;��-.� � , , ESTABLISHMENT NAME: GQ- TAX ID: � � LOCATION ADDRESS: 8 it10. . S^ � � �TEL.#:s' � ; MAILING ADDRESS: � � .Sf• • �-G� � E-MAIL ADDRESS: � ' . , OWNER NAME: �6' .% i CORPORATION NAME (IF APPLICABLE : e.� j MANAGER'S NAME: G. Se.>>' c7�z • TEL.#: J7��= � D.s' s' i NIAILING ADDRESS:�L,f�,C�� /�.'?, �-• d ��1�h+.�.��.� �. .d1�G�O I ; ; 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 - — - __ _ _ _ _ - -- - _ _ _ _ _�--i _ - _ L ._. _- _. _ � Pqol operators must list a minimum of two employees currently certified in 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. 2. � 3.' 4• � i _ , 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. i i 1. 2. ! � P�RSON 1N CHARGE: j Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. � _-�- — -- -..-�-- -- - _ . _ 2 -_�_-__�__ _�_�._ _._._._�___�:_ �. �.___f- _..� - --- • - - � --_�- _�__.___�_._._ _ - , 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 I provide new copies and maintain a file at your establishment. j r i 1. 2. � I HEIMLICH CERTIFICATIONS: ' All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich i 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. t 3. 4. j RESTAURANT SEATING: TOTAL# ---�- ' �-� L 1 L LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I B&B $55 CABIN $55 MOTEL $110 ' INN $55 CAMP $55 SWIMMING POOL$110ea. � LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $1 l0ea. i FOOD SERVICE: ! LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# ' 0-100 SEATS $125 _CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 _COMMON VIC. $60 WHOLESALE $80 � —RESID.KITCHEN $80 RETAIL SERVICE: I LICENSB REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERIVIIT# 4 �<50 sq.ft. $50 �b� >25,000 sq.ft. $285 VENDING-FOOD $25 � <25,000 sq.ft. $150 =FROZEN DESSERT $40 _TOBACCO $110 � NAME CHANGE: $15 AMOUNT DUE _ $ 50 •OU ; ****'�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 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 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 obtained at the Health Department,or from the Town's website at www.Yarmouth.ma.us under Health Department, Downloadable Forms. j FROZEN DESSERTS: �, Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results I� 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. I, OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Board of Hea�th. 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 RETLJRN 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 PLAN. DATE: SIGNATURE: PRINT NAME&TITLE: Rev. 10/O1/15 � � , � : � The Commonwealth ofMassachusetts � Department of Industrial Accidents � Office of Investigations ' I Congress Street, Suite I00 Boston,MA 02I14-2017. www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le�iblv Business/Organization Name: �,q.��,�.� �.P,��-,p.�� c _ Address: �� U d , `Y!ct 7, s�� City/Sta.te/Zip:S�• y,q,e�,,.�.£.�-� , , o�Gc� phone#: �7J�'�.��—as7t� Are you an employer? Check the appropriate boz: Business Type(required): 1.� I am a employer with�employees(full and/ 5. �Retail or part-time).* _ _ 6. ❑ Resta.urantBar/Eating Establishment - - -— --—— --- -- -- - -- — - -- 2. I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real esta.te,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 exemption per c. 152, §1(4),and we have 10.� 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 that checks box#1 must also fill out the section below showing their workers'compensation policy information. ' **If the coiporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#L ; ; I am an employer that is providing workers'compensation insurance for my employees Below is the policy information. f Insurance Company Name: � � Insurer's Address: � City/Sta.te/Zip: � f Policy#or Self-ins.Lic.# Expira.tion Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date). '� _ Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a j 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 verification. I do hereby ify,under the pains and penalties of perjury that the information provided above is true and correct. � _ �, C Si ature: Date: � —L —�S� Phone#: �TbB a3-riS�—us'7 Official use on1y. Do not write in this area,to be completed by city or town officiaL 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 Nou 82 2815 13:31:59 EST FROH: F2M/81877449733 MSGA 75912324-886-1 PNGE BB1 OF BB3 TFiE F4ARFFE)R[s The Hartford FAX COVER PAGE To: Bruce Murphy From: The Hartford Date: 11/02/15 01:31:32 PM Re: proof of coverage for YANKEE CRAFTERS INC Total Pages: 3 including cover page PRIVILEGED AND CONFIDENTIAL:This eleclronic communication,induding attachments,is forihe exdusive use ol atldressee and may � contain proprietmy,confidential andlor privileged intortnation. If you are not the intended redpient,any use,copyin9,tlisdosure, dissemination or distribution is strictly prohibited. If you are not Me intended redpient,please notiTy sender immediately by phone,destroy Mis communication and all copies. � Notes: , Joshua Bertin, Business Insurance Service Operations 1-877-853-2582 (Agents) 1-366-467-3730(Policyholders} 1-S8S-443-G112 (Fau) Email: agency.serv�ces(�thehartford.com The Hartford's Small Commercial Cail Centers have been recogn¢ed by J.D. Pawer and Associates for providing "An Outstanding Customer Service Experience'.Our easy processes and service solutions save time and let your customers focus on whaYs important-their business. For J.D. Pov+er and Associates 2D13 Call Cerrter Cert�cation Program� informatron,visit jdpower.com We care about meeting your service expectations. Did I provide you with a great Hartford Experience7 Piease feel free to send any feedGack on nry service to Tammynrarie.mula@Thehartford.com Nov 02 2815 13:32:iB EST FROM: F2M/81877944733 HSGi 75412324-086-1 PHGE 802 OF BB3 CORd JJB nnrzrvMr�avwvi `�--- CERTIFICATE OF LIABILITY INSURANCE Rooi 1i�z�zo�s THIS CERTIFICATEIS ISSUED ASA MATTER OF INFORMA710N ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE XOLDER.TMIS CERTiFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TXIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE ACONTRACT BETWEEN THE ISSUING INSURER(S).AUTHORIZED R@PRESENTATNE OR PRODUCER,ANDTXE CERTIFICATE HOLDER. IMPORTANT:If the cert�cate holder ia an ADDRIONAL INSURED,the volicy(iar�muct be endoroad. If SUBROGATIONIS WAIVED,subject to tha ta�ms and cendklone ef tha pollcy,urfsln pollelse msy requl�s an anAerosme�k. A etatement on thls eartlflcats Eeea nof wnfe�rlph}s te ths eertificeta holder in lieu of auch andoroement(o). wnE: PAYCHEX INSURANCE AGENCY INC �ac°,"�,�at wc.wa�: (88B) 943-6112 210705 P: F: (888) 943-6112 mo�ea PO BOX 33015 � weu�e�a�w+oiNocweanoe �u��+ SAN ANTONIO TX 782fi5 ir+sun�n: pwin city 'ire ins Co 294b9 qquem INSUR8t8: � IN6URERC: YANKEE CRAF'TERS INC irJsu�o: PO BOX 296 �^�0R6iE: SOUTH YARMOUTH MA 02664 insuneiF: COVERAGES CERTFICATE NUMBER: REVISION NUMBER: THI6 IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 16SUED TO THE NSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITXSTANDING ANV REDUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTNER DOCUMENT WRX RESPECT TO WHICH TXIS CERTIFICATE MAY BE ISSUED OR MAV PERTAIN, TNE INSURANCE AFFORDED BY TXE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TXE TERMS,E%CLUSIONS AND CONDRIONS OF SUCN POLICIES.LIMITS SNOWN MAY HAVE BEEN REDUCED BY PAID CUIMS. �H'T'� TYPFOF/NSORANR a00L SI�HR ry)C/CYNOMBFA wLICYEFF WUCYPRP L/MITS .V.4NDM'YY FACH OCCURRENCE o COMMERCI�L OENERAL L1�91LITY pAA410E TO PEM� 5 CLRIMSM�DE ❑OCCU0. PREMIBEB(EeoaWnnnl MED FX➢(P�Y en�p�nml 6 PEP60NAL6ADVIWUAY s GEN'LOGGREG�TELIMITAPPLIESPER: OENEPaLA00RE�A'IE 6 POLICY �o- LOC PPODUCTS•COMPIOPn00 � JECT 0T11ER: COMBINED SINOLF LIMR AYTOMOBILELIPBILITT � (EIleelOmp 6 •NY�UTO BODRVINJURY(Rrperan) s qLLOWNED BCHEDULED BODILTINJUR'/�Ys�sed0enp 5 AUTOS �UTOS NON-0WNED PROPENT'DMAA�E 6 NIREDPUT08 qU10B IPxseeltl�� 6 UMBRELL�LIAB OCCUR FACX OCCURRENCE 6 EXCE6D LI�B GLMMSM�DE AO(iNEOATE s 6 � DFp REIEMIGN� WfIINHMLYIMIYN,WIIYN X PER OTK S?ATVfE ER .wp4Mvu�vexv�tuam�✓ E.LEiLHACCIDEM 6100 ' ANYPPOPNIEfOWP41iTNERIE%ECVtIVE VIN / �QQ OFFICENMEMBHiE%CWDEOP ❑ w� '(6 WEG NZ16fi1 Oh{Ofi/201h Oh/06/201fi E.LDIBFJIBEFAEMPLOYEE �10�� 000 t1 IMl�throry In NH1 lfyae,MBIXIEaurW�� E.LDISFASF•POLICYLIMR 6,rjQQ�QOQ DEBCRIPTION OF OPEMl10N8 C�low pEfGlNPTION OFOPERiTlDNf/LVGI'IIDNI/YEMIC1.Ei I��ORD 101�W tlkbnY MnxMe BSMW N�mey N eOs[MC II men spea Is npulntl� Those usual to the Insuzed's Dperations. CERTFICATE XOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED TOwn Of Ydrm011th Hedlth De artment BEFORETNE EXPIRATION UATE TMEREOF,NOTICE WILL BE P DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. � Attn: Bruce Murphy AUiHORIlEORE/REDENiAiIVE ` �� 114 6 ROUTE 2 8 �dr2�. /GLt,.(�e^�� 50UTH YARMOUTH, MA 02669 �1988•2014 ACORD CORPORATION.All rlqhts reservsd. ACORD 25(2014107) Tha ACORD nema and loyo are rsylcterad marks o}ACORD tlov 82 2815 13:32:24 EST FROM: F2M/B1B77449733 MSGA �912324-886-1 PflGE �3 OF BB3 AGENCY CUSTOMER ID: LOCM: ��R ADDITIONAL REMARKS SCHEDULE Pa9e or PGENCY R�MEDINBYRED PAYCHEX INSURANCE AGENCY INC POLILYNUMBER YANKEE CRAFTERS INC 5EE ACORD 25 PD BOX 296 � CMRIEfl naiccoue SOUTH YARMOUTH MA 02664 � SEE ACORD 25 EFFECTNEO�TE: SEE ACORD 25 ADDITIONAL REMARKB TXIS ADDRIONAL REMARK9 fORM 19 A BCXEDULE TO ACORD FORM � � FORMNUMBER: ACORD 25 FORMTITLE: CERTIFICATE OF LIABILITY INSURANCE Brian M. Heaslip Asst. Health Agent ACORD 107 (2014101) �$01d ACORO CORPORATION.All righte resrrved. The ACORD nama anA logo ere regisSared marks of ACORD "��`� CERTIFICATE OF LtABILITY INSURANCE 4i2`3i2Do 6� � THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS Nd RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of fhe policy,certain policies may require an endorsement A statement on this certificate does not confer ri hts to the certificate hoider in lieu of such endorsemen s. PRODUCO2 ... CONTACT � . . � NAME: PAYCHEX INSURANCE AGENCY INC �",v�°,N,�,r �a,r,oy: (88$) 443-6112 210705 P: F: (888) 443-6112 E�""" ADDRESS: PO B�X 330�5 . � . INSUREH(S)AFFORDINGOOVERAGE � � NAIC# SAN ANTdNIO TX /�265 1NSURERA: TW1R City Fire Ins Co INSURED � �'�I�;r'2� INSURERB: . . . Q�� ,.�J LSLJ � MSURERC: � � � � �. YANKEE CRAFTERS INC �;-;y' ;.' � 1�� iNsuaea o: PO BOX 2 9 6 � INSURER E: � � � � � � SOUTH YARMOUTH MA 02664 N�ALTH DEPT. ,�„RERF: COVERAGES CERTIFICATE NUMBER: REViS10N NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED: NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDffION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT 70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH PdLICIES.LIMffS SHOWN MAY HAV�BEEN REDUCED BY PAID CLAIMS. r �� TYPEOFIIVSUR9NCE . �D SUBR POytCYNU1ygER POLI� POIlCPEXP . T.Tx�fl,Is � . COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE g CLAIMS-MADE ❑OCCUR DAMAGE TO RENTED $ PREMISES{Ea occurrence) MED EXP(My one person) $ PERSONAL&ADVINJURY g GEN'LAGGREGATE UMITAPPLIES PER GENERALAGGREGATE g POLICY� ECa❑LOC PRODUCTS-COMP/OP AGG g OTHER S AUTOMOBILE W►BILRY COMBINED SINGLELIMIT (Ea aceiderrt) $ ANY AUTO BODILY INJURY(Per person) g OWNED SCHEDULED BODILY INJURY(PeraccideM} $ AUTOS ONLY AUTOS HIRED NON-0WNED PROPERTYDAMAGE AUTOS ONLY AUTOS ONLY (Per acddent) $ 5 UMBRELLA W18 OCCUR EACH OCCURRENCE g EXCESS LIAB CLAIMS-AAADE AGGREGATE g DE� REfENTION$ � � � � � � . . � � $ . . � . iiORKERSCOdfPENS.4TTON �X PER OTH- � � ANDEMPLOYERS'71axn.r�v STANTE. ER �. ANY PROPRIETOR/PAR7NER/EXECUTIVEYM E.L.EACH ACCIDENT $]_O O� O O O OFFICER/MEMBER EXCLUDED? �,yq A (Mand�oryinNH) ❑ 76 WEG NZ1661 05/06/2Q16 05/Q6/2017 E.L.DISEASE-EAEMPLOYEE$100� 000 ' � If.yes.descnbe under ... . ._. -. . . . ,._. . _ __..� . . . . ._ . . ..s DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S O O� �O O � DESCRIPflON OFOPERATfONS/LOCATIONS/VENlC(�RD�01,Additional Remarks 3chedule,may be attached if more spaca is roquirod) I Those usual to the Insured's Operations. ; CERTIFICATE HC3LDER CANCELLATION -=- SHOULD ANY OF THE AB�VE DESCRIBED POUCIES BE CANCELLED Town Of Yarmouth Health De artment BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE p DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. At t n: B r u c e Murphy AU7HORlZID REPRESENTA77VE y 114 6 RO U TE 2 8 "�`'��r ""��,��J,, SOUTH YARMOUTH, MA 02664 � O 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD I � AGENCY CUSTOMER ID: � LOC#: � �� ADDITIOMAL REMARKS SCHEDULE P� of ; � AtiENCY NAMED INSURED PAYCHEX INSURANCE AGENCY INC j POLJCY NUMBER YANKE� CRAFTERS INC i � SEE ACORD 25 PO BOX 296 ca�wER wuccooe SOUTH YARMOUTH MA 02664 SEE ACORD 25 eFFecTnren,arE SEE ACORD 25 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM FORMNUMBER: ACORD 25 FORMTITLE: CERTIFICATE OF LIABILITY INSURANCE Brian M. Heaslip Asst. Health Agent 1 N N N � ._._.__- _.. ___.-_._. . .. ___. .. .._. .._. .. . ._. .__._ . _._....___. ___.-_._ . .._-.._ ..__.._.-_ ___-."_____.._-.._ ___._ .... . ... __ ..._. V __ � O 3 ACORD 101 (2014/01) OO 2014 ACORD CORPORATION.All rights reserved. The ACORD name and logo are registered marks of ACORD i