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� TOWN OF YARMOUTH BOARD OF HEALTH G3C�C�C�O�I�DD
��� APPLICATION FOR LICENSE/PE�tN� 6�'
�, t����(�'�� Dtl; �; I 2U15
* Please complete form and attach all necessary Glocum�n �y necem r I S 2015.
Failure to do so will result in the return ofyour�pptiCation pac t. HEALTH DEPT.
ESTABLISHMENT NAME: iW� l2�aA �STof2�6uT' T ID: — -SSD
LocATioN ADD�ss: �3 �D�i� 6� YA�.,�+ovrH f'�� 'rEL#� ��y - � -a�
MAILING ADDRESS: ' v ; r �v IC b_c
E-MAIL ADDRESS: �3 ..� d t �a2.j
OWNER NAME: � '�L�'�
CORPORATION NAME (IF APP ICABLE): � T���� ���
MANAGER'S NAME: �Y� TEL.#: � -� 6_ a
MAILING ADDRESS: l )
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. Z•
Pool 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.
L 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. ���9 �l��lw'� 2. � � Tf�} �:r��-�� �V\
PERSON IN CHARGE:
Each food establishment must have at least one Person In Chazge (PIC) on site during hours of operation.
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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.
1. l..i O t�y Gci N W 1A`� 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.
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3. 4.
RESTAURANT SEATING: TOTAL # q �'
OFFICE USE ONLY
LODGING:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT It
B&B $55 CABIN $55 MOTEL $i 10
� I1VN $55 CAMP $55 SWIMMMG POOL$110ea.
LODGE $55 TRAILERPARK $t05 _WHIRLPOOL $ll0ea.
FOOD SERVICE:
LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
f 0-IOOSEATS $125 �L -633 CONTINENTAL $35 NON-PROFIT $30
_>I00 SEATS $200 I COMMON VIC. $60 ��Z _WHOLESALE $80
—RESID.KITCHEN $80
RETAIL SERVICE:
LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT#
q >25,000 sq ft. $285 V ENDING-FOOD $25
=<25,000 sq.ft. $150 —FROZEN DESSERT $40 _TOBACCO $110
NAMECHANGE: $15 AMOij��..�UE _ $ ��S�O�
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*****PLEASE TURN OVER AND COMPL�,�fiER SrDE 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 renewai
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 Aealth 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 WATEIt 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 fonns can be
obtamed 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 priar 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 Board 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 LAN.
DATE: I (� � I�� SIGNATURE: �'�G �� ��� "'�
PRINT NAME & TITLE: � '�!� 1�.
Rev. 10/Ol/IS
,4co n' CERTIFICATE OF LIABILITY INSURANCE °"'�`"w°°""""
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THIS CERiIFICATE IS ISSUED A$A MATTER OF INFORMATION ONIY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY TME POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT; It the ceRificate holder is an ADDITIONAL INSURED,the policy(ies) must be entlorseE. If SUBROGATION IS WAIVED,subject to
Ne temts and condkions of the policy,certain policias may require an endorsement A statement on this certificale tices not coMer rights to Me
certifiwte holder in lieu ot such endorsement s.
PROOUCER ��T^�T Norah Mccormick
NM1E:
Waquoit Insurance Agency °XDNE . (508)590-1919 F� .(508��5'l-1269
516 Waquoit Highway �"�� .�ccoxmick@mccoxmickiasurance.cam
INSURE S IIFFORDINGCOVERAGE NAIC:Y
Waquoit 19� 02536 wsunersn:Western S�orld Insurance C an
INSURED MSURERB:SCOttSCId1E Insurance company
TREVI RESTAi7RANT GROIIP ixsurtersc:
43 Rte 6A wsuxenn:
INSURER E:
Yarmouth Port MA 02675 INSURERF:
COVERAGES CERTIFICATE NUMBERCL74112102232 REVISION NUMBER:
THIS IS TO CEP.?IFV THAT THE POLICiES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANV REOUIREfAENT. TERGA OR CON�IT'ON OF ANY CONTRACT OR CTHER DOCU"dENT VJ!TH RESPECT?O WH!CH THIS
CERTIFlCATE MAV BE ISSUED OR MAY PERiAIN. THE iNSURANCE APFORDED "nV THE POLIGES DESCPobED HEREIN i5 �UBJEGI TO AiL iHE TERMS.
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CERTIFiCATE HOLDER CANCELIATiuN
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SHOL'LD 4NY OP i HE A6QYE DESCRIBED PCLICiES BE Cl+4CELi£�BF.PoR.E �
i THE EXPIRATI04 �ATE THEREOF. NOTICE WIIL 8F DEIIVF.RED IN �
TOw.^. Of Yd�IItCu�?'. �1��OROANCEWIIMTHEFOLICYPROVISIONS. i
Yar.nout'�. MA �
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AG�RO 25(20,^'n':, _'?986-2010 ACORD CORPORATION. All rig��ts reserved.
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` ;`" t� The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02II4-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Aunlicant Information Please Print Legiblv
Business/Organization Name: � '��J � �'a���r�.j�`���•�� l�r>� / �� .Nl��.���
t,� � � � � .
Address: -i , �a in'�
City/State/Zip: "; _< � � i� .�'� `��^��%`Phone#: ,���I � �.�� ' ���C
Are you an employer? Check the appropriate boa: Bnsiness Type(reqnired):
L[`� I am a employer with �a employees(full and/ 5. ❑ etail
or part-rime)* 6. �RestaurantBaz/Eating Establishmern
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. insurance required] 8• ❑Non-profit
3.❑ We aze a corporation and its officers have exercised 9. ❑ Entertauunent
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufachuing
no employees. [No workers' comp. insurance required]* 11.� Health Caze
4.❑ We aze a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.❑ Other
•Any applicant thaf checks box#1 must also 5ll o�rt the section below showing[heir workers'compensatioa policy information.
**If the co:porate officecs have exempted themselves,but the corporation has otha employees,a workecs'compensation policy is required and such an
organ'uation should check box#1. �
I am an employer that is providing workers'compensarion insurance for my employees. Below is the policy infarmation.
Insurance Company Name: �',�yst�� ,.1- t1 i�t t a n[� P��y
" 1, (((
Inswer'sAddress: �� � �,�� J6�q�1 ii�:� �
City/State/Zip: � � '� � � 4 �'
Policy#or Self-ins. Lic. # !V 1 1 ��0 C%��� Expiration Date: � �D ��
Attach a copy of the workers' compensation policy declaraaon 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 imposition of criminal penalries of a
fine up to $1,500.00 and/or one-yeaz imprisonment, as well as civil penalfies 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
Investigations of the DIA for insurance coverage verificarion.
I do hereby certi ,�n the pains and penalties ofperjury that the information provided above is true and correct
Si ature: Date:
Phone#:
Official use only. Do not write in this area,to be comp[eted by city or town offuial
City or Town: Permit/License#
Issuing Authority(circle one): :
1.Board of Health 2. Building Department 3. CityPTown Clerk 4.Liceasing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia