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Home My WebLink AboutApplication and WC �' �' ° �� or�� ` TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSE/PERMIT- 016. ,� . � �� '� L�i�'r � � � �� ' " * Please complete form and attach all necessary docur�.en�s°by becem er S_ 4 - p i ' Failure to do so will result in the return af your application pac . "---�--------`-T..°�.._„ '. � I ESTABLISHMENT NAME: J f TAX ID: � LOCATION ADDRESS: I ,'., F} TEL.#: --d!t MAILINGADDRESS: 4 �Gk 1(65 �1.�+cr ,� Y�,` 971t.�s E-MAIL ADDRESS: ei -„-� ri-4-ea��-Ca�-� OWNER NAME: �-c� C• ( CORPORATION NAME (IF APPLICABLE): MANAGER'SNAME:`�Q�n.a� �1�- TEL.#: I ; NIAILING ADDRESS: I , POOL CERTIFICATIONS: `(��G-' 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 _ __._._._��... ,_�` _ � e: ___��__ -- -- ___ � 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• i 3. 4. j 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. 1. 2. PERSON.IN�HARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ; � _ � —__�1..�.�:_R_ _- __ _� 2 _ ALLERGEhT 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 copies and maintain a file at your establishment. 1. 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. � L 2. • � 3. 4. � � RESTAURANT SEATING: TOTAL# _ _--- - -- __ f3��E USE�i'+�TLI' _ LODGING: ' , LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 _INN $55 CAMP $55 SWIMMING POOL$110ea. ' _LODGE $55 _TRAILER PARK $105 _WHIRLPOOL $110ea. ' 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: � LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <SO sq.ft. $50 >25,000 sq.ft. $285 VENDiNG-FOOD $25 �=<25,000 sq.ft. $150 � =FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE _ $ �� .OQ ' *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** � � j � Y � . a � ��1 1 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 i WORKER'S�COMP. AFFIDAVIT SIGNED AND ATTACHED � i Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK � APPROPRIATELY IF PAID: f YES NO � MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy sha11 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.Transi�nt 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 axea 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 _ �losing. ----__ _ 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 obtamed at the Health Department,or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: I 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 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 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 SIT LAN. � DATE: SIGNATURE: � �*- /f -��-�---' � PRINT NAME&TITLE: i I��/la� I �- p�d�li,�rc: �tc c ��s'�d�.f Rev. 10/O1/IS i � .��,_� :�� 1Jte Cunrmvinv�ul//t uf,{/irs�•u�•lursetl.s r �- --= DE��urU�ren1 ��f I�r�lrrs�riu!;I ec•irleirls 1� , �� Ullice vf lirvrstigu�io�rs � ' 600 �Yushi�rg�on Streel , �, ' ;: 13osron, tb1.102111 `''-- � ►vww.mass,�ov/dia �Vorkers' Compensation Insurance rlffidavit: General E3usinesses ;1Qplicant [nformation Please Print Leaibiv Business/Organization Name: ��-c_ �r��.=� j('�� t\c�Jress: "I �� ('nk r � C�' �} Ci ty/S t�te/Zip: i �h �rr-F (kZ'o`75 Phone 1#: 5 �-' �2��/ A e ynu an empioyer?Check the�ppropriate box: Qu ines�Type(requireJ): 1.� [am a employer with �� -�' employees(fult and/ 5• �Retail ��c part-time).• 6. ❑ Restauran�EariEating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. �O�ice and/or Sa(es(incl.real estate, auto�etc.) emptoyee� working for me in any capacity. [No workers'comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and itt o�cers have exercised 9. ❑ Entertainment thefr right oFexemption per c. 152, §1(�i).�nd we have 10.Q Manuf�chuing . no emptoyee�.(No workers' comp. insur�nce requireJJ• 4.❑ 1Ve�re a non-profit organiz�tion,staffed by volunteers. ��•� Fiealth Care with no employeea.[No workero'comp, insurance req.] 12.Q Other •Any�pplieant that checic�bme MI must also fil)out�ha section below showind theirworken'compawifon rtoUry infoemation,' . ••If the corporats ofiicen have e�cempted themxfva,but the corpaatio�h�other empioyee�,s worken'compensatioe pu�iep ia rcquired and such aa nrganiratian should check box Ml. I arn an eirrp/oy�r fhal Li provr g workers'conrp nsa�lon tn.raranee jor my enip/oye��Bdow ia the policy injorma�ior� Insurance Company Name: 1 rCtV�. ��✓S ` iT (nsurer's AdJress: ' � City/State/"Lip: Policy �or Self-ins. Lie.�ll ! 1��- rc� C�"�T�� S Expiration Date• �' � �(E ,\ttach�copy of the worker�'compensation policy�leciaration page(showing the policy number and e:piratlon d�te). F�iilure eo secure cuver�6e�s required under Section ZSA of 1�iGL c, l52 ca�IeaJ ro the imposition ofcriminal penalties of a tine np!o S I,SQ0.00:indlor�ne-year imprisonment,�s well.�s civil penalties in the fonn ofa S"I'OP WORK ORDER and a fine uf up to S25Q.00 a �lay igainst the viotator. f3e aJviseJ that�copy of this statement may be foRv�rdeJ to the Office of � ' Investigatiorts uf the DGl for insu�;tnce coverage verific�tion. 1 Jo hereby cer�l/'y, uade the pain,, n Penaltie.t v/'prrjury�ha!�he informution provided��bove i.t hrrt and ca►recG �� ' Si�huc: - D�te: 'hune �� .. � Of�ciu!use�nly. Do not w�i�e rrr this area, Iv be cornpleted by rrty ur town v%frciu� � ' f I City or To�vn: _ Perrnit/[.iee�tse�i � - -- , (tisuing :�uthority (circle��ne): — --- i , 1. fTu.irr) of(te:ilth 2. f3uil�lino Dep:irtrnent J. ('ityi('u�vn ��ferk 1. LicenSin; 13�.�r�) S. Selectmen'4 �)(fice ' fi. 1)thcr � � ('nntact t'er��►n: t'hnne/!. � ' -- _ -- ---- -- __ __ -- --- ---_-- — - ----__ �. — -------- —--- ---- --- — --- _ _, -- -____._ _ __------ --- -- --------�— �--_ _ — _..-------------- � � / . � DATE(MMIDD/YYYY) A�oRo� CERTIFICATE OF LIABILITY INSURANCE 1/7/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONIY AND CONFERS NO RIGHT3 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 13SUING INSURER(S), AUTHORI2E0 REPRESENTATIVE OR PRaOUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the ceRiftcate holder is an ADDITIONAL IN3URED,the policy(ies)must be endoraed. If SUBROGATION IS WAIVED,subject to the tenns and conditlons of the policy,certafn policies may require an endorsement. A statement on thls certiflcate does not conier rights to the certiflcate holder in Beu of such endorsement s. PRODUCER NnONMEACT Guadalu e Vera Arthur J. Gallagher Risk Management Services, Inc. PH�� .212-9947100 F"X .212-994-7047 250 Park Avenue E-MAIL 3rd Floor .Guadalupe_vera@ajg.com New York NY 10177 INSURER S AFFORDING COVERAGE NAIC N INSURERA:TfBV@IBfS Pf0 e Casuai Co of A 25674 INSURED INSURER B: Rite Aid and Affiliates INSURERC: 30 Hunter Lane Camp Hill, PA 17011 INSURERD: INSURER E: INSURER F: C VERAGES CERTIFICATE NUMBER:235140864 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. N0TIMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VNTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR .n��F�g�� POLJCY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDWYYYY MMIDD/YYYY u�Ts COMMERCIAL GENERAL 1IA81LITY EACH OCCURRENCE 3 CLAIMS-MADE �OCCUR PREMISES Ea occurrence 3 MED EXP(My one person) S PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 POLICY❑ PR� �LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: $ auroMoe��uaeiurr Ea accident $ ANY AUTO BODILY INJURY(Per person) S AUTSS E� AUTOSULED 80DILY INJURY(Per acadent) 5 NON-0WNED $ HIREDAUTOS AUTOS Peraccident a UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS IJAB CLAIMS-MADE AGGREGATE $ DED RETENTION S $ q WORKERSCOMPENSATION TC2JU8-120D221&15(AOS) /1/2015 1/1/2016 x AND EMPLOYERS'LIA&UTY � STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N�A E.L.EACH ACCIDENT $2,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE 32,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Addldonal Remarks SchaduN,may tw atfacMd H more apaae is required) Evidence Only � i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Insurance ACCORDANCE WITH THE POLICY PROVISIONS. • • • AUTHORIZED REPRESENTATIVE ! � ' _'�"` i I O 1988-2014 ACORD CORPORATION. All rights reserved. i ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD C � _ I