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Home My WebLink AboutApplication and WC �� -�..31��,268 � TOWN OF YARMOUTH BOARD OF HEALTH ,' Y� � � . �l�� ,�.�_. _,�� :� � � � APPLICATION FOR LICENSE/PE�'1� .� � : ;� NO� �� 1� "'°" * Please complete form and attach all necessary c�ocutn��ts,�� ec�xnb.r 1 S, 201 S. Failure to do so will result in the return o�'your�ppli�ation pac t. ��E`-,�,.�?-�t ;r-;r_�>T� E"�TABLISHMENT NAME: u�n � �ns aa TAX ID• ��`�� LOCATION ADDRESS: ' S7' o�U�� TEL.#: S�� /-!/�3 MAILING ADDRESS;/c7 �',•Q 5 ' 1 R , d/ � �- E-MAIL ADDRESS: �i�L tJG�CG i" r,-,�;,��-�ct� -� � .. Go� OWNER NAME: � � s ��,. CORPORATION NAME (IF APPLICABLE): ('��,�r�,�lyr✓c� �r�� -C- MANAGER'S NAME: `�R,"n� �Ia �-i �`h��- TEL.#: S"o�r-79/-�(/�� MAILING ADDRESS: 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 for�n. � 1. 2. 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. 1. 2. 3. 4. F�4��-E�T��'�ni.�-i�_n i.r--��r^-.��--C�E��'��C A�I4�TS: . 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 1. �✓�Gt I ' l C� F`7�i �1 �Z_ 2. �CC-�S�L�ld' �G'l�/'I � Z /Q/L' � i I PERSON 1N CHARGE: ; Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. i � � 1. ��'.,� �cr_r`�� 'n e-z- 2. --�c� _54'h/ 2lPh eZia�✓ 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 j 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. t � n� � �� , , 1. ! ,2 ,'.-,c,� ! ' I��^�- ,`�� -L 2. c� s�rf-r e�t�Z ict.r.� � , 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. 2. F 3. 4. RESTAURANT SEATING: TOTAL# ! _ ------.,�+'�'��`LY--_� — _ ______--�--- � LODGING: I LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# I _B&B $55 CABIN $55 MOTEL $110 ; -INN $55 CAMP $55 SWIMMING POOL$i l0ea. _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $I l0ea. � FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERM[T# 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: LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 , �<25,000 sq.ft. $150 =FROZEN DESSERT $40 �TOBACCO $110 NAME CHANGE: $�s AMOUNT DUE _ $ 260.00 *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** Y , 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 1NSURANCE 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 MOTEI.S AND OTHER LODGING ESTABLISHMEN�'S 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. FO�DD 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. I� CATERING POLICY: I 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 obtamed at the Health Department,or from the Town's website at www.�azmouth.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 Board of Health. OUTDOOR COOKING: 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 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 RD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN DATE: f�,�� /-S SIGNATURE: PRINT NAME&TITLE: ich rd Fournie x Man�ger ' Rev. 10/O1/15 I I a � � The Commonwealth o f Massachuseus Departm¢nt aflndustria[Accidents I Congress Street,Suite I00 a � Boston,ltlA p2114-2017 � I www.mass.gov/dia I Workers'Compensation Insurance Aftidavit:General Bus�n�s�. TO BE FILED W(TH THE PERMI7TING AUTIipR11y. � A licant Information Please Print Le 'bl Business/Organization Name:Cumberiand Farms, Inc. Address: 100 Crossing Boulevard City/State/Zip:Framingham, MA 01702 Phone#:508 2701400 Are you an employer?C6eck the appropriate box: 1• ✓O I am a employer with 3�146 Business Type(required): employees(full and/ 5• �Retail or part-time).* 2.❑ I am a sole proprietor or partnership and have no 6• ❑RestaurantBar/E��ng Establishment employees working for me in any capacity. �• ❑D�ce and/or Sa1es��ncl.real estate,auto,etc.) [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 no employees.[No workers'comp.insurance required)* 10.0 Manufacturing 4.❑ We aze a non-profit organization,staffed by volunteers, 1 I.Q Health Care ' with no employees.[No workers'comp,insurance req.) 12.0 p�er "Any applicant ihat checks box�/l�d them'selves but h p��W sh�ng�eir�►rorkers'compensetion policy i�p�tion. **If the corporate officers have ex organizadon should check box#1. ��tion has other employees,a workers'compensetron po�� s �Y re9uired and such an I anr an employer that is providing workers'compensation insurAnce for my emp/oyees B%N,is the policy injornration. Insurance Company Name:ACE American Insurance Company Insurer's Address:33 Arch Street, Suite 2900 � City/State/Zip: Boston, MA 02110 � I Policy#or Self-ins.Lic.#SCFC48148141 Attach a copy of the workers'compensation policy declsration page(showidg the poucy p�'4/1/16 Failure to secure coverage as required under Section 25A of MGL c. l52 can lead to the im �ber�d.expirat3on date). fine up to$1,500.00 and/or one-year imprisonment,as well as civi]penalties in the form of a STpp W criminal ' of up to$250.00 a day against the violator. Be advised that a copy of this statement may be fony �n�t��of a �RK ORDER and a fine Investigations of the DIA for ins ce coverage verification. �'ded to the O�ce of I do hereby cerG'fy,unde e a ties oJper,�ury that the information provided �is true and correc� Si at re• � � Da e• • � � P n •5 d � ^-� � ,._ .—� f � i I O,JJ?c!p!use only. Do not write in this ureq to be comp/eted by city or town offrcial. ` f City or Town: � Issuing Authority(circle one): permitlLicense# l.Bo�M of Heslth 2.Building Department 3.City/Town Clerk 4.Licensing Board S. , 6.Ot6er �kctmen s Otlice Contact Persoa: Phone#• www.rness.govidia I � f _ � � ACORO• DATE(MM/DD/YYYY) �,.....--- CERTIFICATE OF LIABILITY INSURANCE 03/27/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RICaHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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 be endorsed.If SUBROGATION IS WAIVED,subject to m the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate dces not confer rights to the � certificate holder in lieu of such endorsement(s). � � � PRODUCER CONTACT ,a �' Aon Risk Services Northeast, inc. ��0 Provi dence RI Offi ce jac.No.Ext): �866) 283-7122 ac.No.: 800-363-0105 `y 'a 100 Westminster Street, lOth Floor E.�u� o Providence RI 03903-2393 USA noortess: _ INSURER(3)AFFORDINO COVERAGE NAIC# INSURED HJSURERA tndemnity tnsurance Co of Horth America 43575 CUMBERLAND FARMS. INC. INswteRB: ACE American Insurance Company 22667 100 Crossing eoulevard Framingham MA 01702 u5A xusur�Rc: ngri General Insurance Company 42757 INSURER D: . . . -. � INSURER E: INSURER F. � i COVERAGES CERTIFICATE NUMBER:570057155877 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested �ra TYPE OF IN3URANCE �p POUCY NUMBER M�yp MMIDD/YYYY LIMITS � � COMMERCL4L GENERAL L.IqBILJTY EACH OCCURRENCE CLAIMS-MADE ❑OCCUR PREMISES Ea oeeurtence MED EXP(Any one penon) PERSONAL 8 ADV INJURY n GEN'L AGGREGATE LIMR APPLIES PER: GENERAL AGGREGATE � PRO- P��CY JECT �� PRODUCTS-COMP/OP AGG r� OTHER: p 0 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT � Ea a 'ent ANY AUTO BODILY INJURY(Per person) O '��, ALL OWNED SCHEDULED �BODILY INJURY(Peraccident) Zy � AUTOS AUTOS � .. HIRED AUTOS NON-OWNED PROPERTY DAMAGE � �� AUTOS Peraccident ,� .. t' m UMBRELLA LIAB OCCUR EACH OCCURRENCE V � EXCESS LWB CLAIMS-MADE � � � AGGREGATE DED RETENTION A WORKERSCOMPENSATIONAND WLRC4814813A 4 O1 15 04 O1 2 1 PER OTH- EMPLOYERS'LW&LITY X STATUTE � � ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N work Comp-- --q05 � � B OFFICEwrnEMeER�ccLUoeD7 �N/A SCFC48148141 04/Ol/2015 04/Ol/2016 E.L.EACHACCIDENT S1,OOO,OOO ' (MendaMry in NH) work Comp-- -Mq E.L.DISEASE-EA EMPLOYEE Sl,000,000 tt yes,deseribe under DESCRiPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT� $1,OOO,OOO— � � DESCWPTION OF OPERATIONS/LOCATION3/VEFXCLES(ACORD 101,Addilional Remerks SeheduM,may be attaeMd ff mon spac�is requircd) � .: The insurance afforded by the policy described herein is subject to all terms, exclusions and conditions of such policy. � +J � � � I � E CERTIFFCATE HOLDER CANCELLATION � ti � � SHOULD ANY OF THE A80VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOP, NOTICE VNLL BE DEWERED IN ACCORDANCE iMTH THE - POLiCY PROVISIONS. � TOW1l of varmouth AUTHQRIZED REPRESENTATNE ■ rown Clerk 1146 Route 28 - ; South Yarmouth MA 02664 u5A �J' t��]j „�� c�ya �'�.�uE" � I 01988-2014 ACORD CORPORATION.All rights reserved, t ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i r i