HomeMy WebLinkAboutApplication and WC ; �DoY�s'�
� a TOWN OF YARMOUTH BOARD OF HEALT
1��� APPLICATION FOR LICENSE/P T'�Ol ���� Nf?`� 'i�I�
� r�;� k ��
* Please complete form and attach all necess cu�ent y �isedi'�i r 1 �2015 _,�;T
Failure to do so will result in the return ouf�pprcat�on pac . --.______.__,_�
ESTABLISHMENT NAME: AX ID: '
LOCATION ADDRESS• I 2q 7. in TEL.#: OB-'J/oO-)��
MAILING ADDRESS:
E-MAIL ADDRESS: '
OWNERNAME: l� " Ilo.vi u.
CORPORATION NAME (IF APPLICAB E): Z :
MANAGER'S NAME: U)nn SU✓D TEL.#:
MAILING ADDRESS:
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operat r(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 standard First Aid and Communiry '
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 £le at your place of business.
1. 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.
L �i�r� �i0.W� Jwr_P��}c�N � 2.
PERSON IN CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
__ - - _-_ _ -- - - — - __ _ - -
: _ _ _ I
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 co�ties and maintain a file at your establishment.
1. �A I II � ,.��1-'�A� .�� 2.. i "CCt,t�L� Y' 1 ( f—/1N i
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 maintain a file at your place of business.
1. �,A-Nkaa- �J i I n X 2. � T �o.�/� Ic�
3. oJ� ,v Il,� �-- 4. �N rtz kPllrr
RESTAURANT SEATING: TOTAL# ��4_
_ �c��: _
_ OFFIC�SF_n� _ — ---
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# LICENSE AEQUIRED FEE PERMIT#
B&B $55 CABIN $55 M07'EL $1I0
INN $55 �CAMP $55 SW[MMINGPOOL$IlOea.
LODGE $55 TRAILER PARK $105 _WH[RLPOOL $110ea.
FOOD SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUtRED FEE PERMIT#
0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30
j>100 SEATS $200 �7 �COMMON VIC. $60 _(�(o _WFIOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
q >25,000 sq ft. $285 VENDING-FOOD $25 �
=<25,000 sq.ft. $150 —FROZEN DESSERT $40 � _TOBACCO . � $t 10
NAMECHANGE: $15 AMOUNTDUE _ $ Z6�•OO
*****PLEASE TURN OVER AND COMPLETE OTNER SIDE OF FORM•****
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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 Yannouth 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 ofMotel 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 aze 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 OPEPTING:
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
requued 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.yazmouthma.us under Health Department, I
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 Pernut unril 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. i
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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, 2015.
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 REQUIRE A SITE PLAN. �
DATE: D 6 SIGNATURE:
PRINT NAME & TITLE: W 3 (6 �,�� �l!/'g-�v o�-�/ Q�j►4j� j
�
Rev. 10/O1/IS
�
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i
, . . � The Commonwealth ofMassachusetts ,
Department of Industrial Accidents
Office of Investigations �
� I Congress Street, Suite Z00 �
Boston, MA 02114-2017
www.mass.gov/dia l
Workers' Compensation Insurance Affidavit: General Businesses !
Aualicant Information Please Print Le�iblv I'
1
Business/Organization Name:���1�_ i
Address: 1'3'�� `1" � '
City/State/Zip:S. � (o Phone #: �d'S � ��cd���
Are you an employer? Check the appropriate bos: Business Type(required):
1.�am a employer with �J employees(full and/ 5. ❑Retail
or part-time).' 6. �RestaurantBaz/Eating Establishment
_ _ — - __ —_ -- ----_ —
2.Q I am a sole propnetor or partners i�i p and�ave 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 aze a corporarion and its officers have exercised 9. ❑Entertainment
their right of exemption per c. I 52, §1(4),and we have 10.�Manufachuing
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 thaz checks box#1 must also 5ll out the sec[ion below showiag their workers'compensa[ion policy infotmatioa. '
*•If the wtpom[e officers have exempted themselves,but the cocporation k�as other employees,a workecs'compe¢sation policy is required and such an "
organiTation should check box#7. - �
I am an employer that isproviding workers'compensation'ins/urance for my employeers. Be[ow is the policy infarmation. ,
Insurance Company Name:�� , �/ �� �c �C`.� r° i�,a�� � 77�—��� �
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic. # Expiration Date:
Attach a copy of the workers' compensation policy declaration page(showing the policy nnmber and eapiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposiUon of criminal penalries of a
- fiaaup to $?;5()�.1-0B e�/er one-yeafi:�rsernnent,as�vell as civil�enalties ir.the form afaS�'OP 9�flRK fl�DER 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
Investigations of the DIA for insurance coverage verificarion.
I do hereby certify,under the pains and penalties ofperjury thai the information provided above is bue and correct.
Si ature: Date: � �
Phone#: 6 � �"� O �
Ojficial use only. Do not write in ihis area,to be completed by city or town officiaL ,
City or Town: Permit/License# I
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
_ ,
DATE Nov- 05 -2015 '
TIME 14:01:44
PAGES 1
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TO Town of Yarmouth; Attn: Philip Renaud
COMPANY
I
FAX NUMBER 15087603472
NOTE
FROM Linda Sullivan
COMPANY Dowling & O'Neil Insurance
VOICE NUMBER 508-957-4270
FAX NUMBER 508-957-4810
�
Cliont#: 76383 ZDOYLESREt
ACORO� CERTIFICATE OF LIABILITY INSURANCE °„�`"""°�'�.��,
,vos�ze,s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAT�N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.7NI3
CERTIFICATE DOES NOT AFFIRMATNELV OR NEGATNELV AIi1END,E)ITEND OR 0.LTER THE COVERAGE kFFORDED DY TFIE POLICIES
�BELOW.THIS GERTIFICATE OF IN3URANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUING INSURER�(3),AUTNORIiED
REPRESENTATNE OR PROOUCER,AND THE CERTIFICATE HOLDER. .
IMPOR7ANT:Rths cen�ficats holdar io an ADDmONAL INSURED,the oo�icy(�es)must bo endoised.If SUBROGATION IS WANED,subjeet to
'. the iarms and eondi�ions of tha poliey,eenain polieies may repuire an endorsemeM.A otatamefrt on this certAicate doee not coniar righK to tha
cenifipN holder in GQu af eueh endorseme ry� �l (7�p
.. . . � L.�`^�J V ,�� �wie i
YRDUUCtN � D N11Yt:
. Uowling 8 O'Neil Insurance Ag v�NN E .Spg 77y7620 ".� N,,: SU87787218
. 973 lyannough Rd, ro sox�9so NOV p 5 2p�5 `x„`
H annis,MA 02687 ���35�
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50i 775-7620 �-{Ej�i„j_i E `J�P� . ir+cuecKn:Tudor Insuranca Campany
�NGUNtU INgVRER e:T�H2MOfA
ZDOM,Inc. DIBIA Doyla's Rastaurdnt �
miuucKe:
� A!O Bispue Boy Realty Trust
INSVRER D:
� 1329 Route 26 �
wsuHCK c:
. So[Rh YarmOuth, MA 02664
INSURER F:
WVERJIGES GERTIFICATENUMBER: REVISIONNUMBEft:
I THIS IS T6 CERTIFY 7HAT 7HE P(M.ICIES OF INSURAN(:E LIS7ED BEL(ri�/ HAVE6EENISSUED 707HE INSl1RED NAMEUABOVE GOR7HE POLICYPERIqU
INDICA7E0. NOnNITHSTfJJDING ANY RE�UIREMEM, T'eRM OR C�IDRIONOF ANv CONiRACTfJR O7HER OOCUMEM wITH RESPECT 70 WHICH THIS
GERTIFICATE MAV BE ISSJED �R MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICI'c5 DESCRIBED HEREIN IS SUBJECT TO /iLL THE TERMS,
EXQLUSIONS ANU C(MJOI710NS OF SlJ(:H POLICIES. LIMRS Si�WN MAV HAVE 6EEN REDUf:EU BV PAIO CLAIMS.
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$2,000,000 aggregate
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Operations peRormad by the named insured subject to policy conditions
and exclusions.
CERTIFICATE HOLDER CANCELLA710N
roW n a ra�mo�cn SHOV LD ANY OF TNE ABOVE DESCW BED POLICIES BE GANCELLED BEFORE
THE EXPIR4TION D41E THEREOF, NOTCE NALL BE DE�NERED IN
License Dept. nccoRoa� �NNTF� TFIE .OLICY CROVISIONS.
7746 Route 28
.. SouthYarmouth, MA 02664 A07NOR¢EDREiRE9ENTATNE
"7r'J'_.'E'— `.G''^""s'�`w,..
�. 9 798&2070 AGORD GORPORATION.All righb reaerved.
. ACORD 25(2090/05) 1 of 1 The qCORD name and logo are regcnretl marko of ACORD
i5160595/M760592 � � � L51
� .. _... .._. _ ._. . �