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Home My WebLink AboutApplication and WC � Q�DC�, tti S r. _.. .cr1a�.=t�r�o� � a � TOWN OF YARMOUTH BOARD OF HEALTH - ' ! � � . � ; : � � APPLICATION FOR LICENSE/PERMI'�'-`��16C��'�, ��;;��' , � �k'�� , , �� y. , * Please complete form and attach all necessary docum�nts by Dec� b r 1 S 201 S. � ' Failure to do so wi11 result in the return of your�p�li�ahon�ia �et:-' ' -' - ' T" '` } E�TABLISHMENT NAME: L-�- TAX ID: - , LOCATION ADDRESS: 1 I `NtGt+� �'�C�" 3��E�' TEL.#: --^I O a6 �. , MAILING ADDRESS: �m� � �� • ! E-MAIL ADDRESS: o� �2� . c��nn. , ; OWNER NAME: 'Co� � 6 � � , CORPORATION NAME (IF APP ICABLE): �1� �+� 1VIANAGER'S NAME: �c.1�nn u.�--( ��o TEL.#: .�p�--�Ib el�c��a : MAILING ADDRESS:��,nelr�za [�r , Cct�n �'�l.�F- o�-��-� + POOL CERTIFICATIONS: The pool supervisor must be certifed as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certi�ication to this form. ---- - - - - -- ---- -- - - ---- ____,__-.— - __ _- 1 1 _ �: -- —__ Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), havirig 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 4 years' records. You must provide new copies and maintain a file at your place of business. ; ' I L 2• �i 3. 4. j ; i i FOC�D 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 �le at your establishment. ' 1. �v� .d.�r �'{°�a 2. i� PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. �Q�u�..� ��a • ----a-_-- -- -- -- —_ __- _ 2.=._._._��. _._... __-�____�.._ ___.�_..._. __ __�__�._:_.__- ---��r_—_-,----- � 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 ' provide new copies and maintain a file at your establishment. 1. ►'r1 �--�t� 2. I HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlieh 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• 3. 4. RESTAURANT SEATING: TOTAL# �� — ---___ _ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $110 [NN $55 CAMP $55 _SWIMMING POOL$110ea. LODGE $55 TRAILER PARK $105 _WHIRLPOOL $1 l0ea. FOOD SERVICE: LICENSE REQUIRED FEE P RMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �0-100 SEATS $125 �j�„�8( CONTINENTAL $35 NON-PROFIT $30 _>100 SEATS $200 �COMMON VIC. $60 rOEJ� WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE 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 NAMECHANGE: $is AMOUNTDUE _ $ 185.�0 *****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 1NSURANCE ATTACHED V 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 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.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 qua�terly 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. 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: �I 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 RETLTRN 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 PPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ RE A SITE PLAN. � DATE: 1\ 14 �5 SIGNATURE: ` ' I PRINT NAME& TITLE: �G�,V�1� �� Q� � , Rev. 10/O1/15 i , � � The Commonwealth of Massachusetts Department of Industrial Accidents • Office of Investigations � 1 Congress Street, Suite 100 Boston, MA 02114-20�7 www.mass.gov/dia Workers' Compensation Insurance Affidavi�: G•eneral-:Businesses ; - � Apulicant Information Please Print Legiblv Business/Organization Name: �D ic- - T1 �- (�0 L�—� Address: } � � (�,i t v� �'�' �,�`� �r � � City/State/Zip: �- �1��°�� `� Phone#: �°8 �6� `�2 a�� , Are you an employer? Check the appropriate boz: Business Type(required): l.� I am a employer with��employees(full and/ 5• ❑Retail or art-time).* 6. ,�,/ RestaurantlBaz/Eating Establishment I __� - — — . -------- _---- 2. I am a sole proprietor or partnership an�have no �, � Office and/or Sa1es(incl.real estate,auto,etc.) employees working for me in any capacity. g. �Non-profit [No workers' comp.insurance required] 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]* 11.0 Health Care � 4.❑ We are a non-profit organization,staffed by volunteers, ! with no employees. [No workers' comp. insurance req.] 12•0 Other i *Any applicant that checks box#1 must also fill out the secfion below showing their workers'compensation policy information. j **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an I organization should check box#L I am an employer that is providing workers'compensdtion insurance for my employees. Below is the policy information. ': � Insurance Company Name: 1��(' Q� V�0.�-�✓��d ;n�ufQ�C Q � �1� � �1S ��, , � � � Insurer's Address: �� '�t�`�'r �' �� . ', �iTy/�tate/Zip. ��`� n •� . Policy#or Self-ins.Lic.# I'��C `r�� 2� 3� �� ' Expiration Date: Attach a copy of the workers' compensation policy declaration page(showing the policy number and egpiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as welI as civl penaTties in tlie form o�aSTOF��IIR��-an�a�ne — 'i 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 cert ,under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: 4 � � � �� Phone#: �� b� .-�pCj`� ` Official use only. 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#• i www.mass.gov/dia � � � � ACO� oaTE(MMrowrnrr� CERTIFICATE OF LIABILITY INSURANCE 10/29/2015 � THIS CERTIFICATE IS ISSUED A5 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTiFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIYE�Y 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), AUTHORI2ED i REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. � IMPORTANT: If the certiflcate hoider is an ADDITIONAL INSURED,the policy{fes)must be endorsed. H SUBRO(iATION IS WANED,subje�t to ; the terms and condkions of the policy,certain policies may require an endorsement A statement on this certificate does not cor�fer HgMs to the i certificate holder in lieu of such endorsement(s). i PRODUCER �E: Andrew Roth MURRAY S MACDONALD INSURANCE SERVICES� INC. P�NE ; (SOS�2S�'I5Z N,,�; E'uia� aroth mmisi.com noor�ss: @ 550 MACARTHUR BLVD. iNsuttE S AFFORDINGCOVERAGE wnica j BOURNE MA 02532 ir�sur�RA: AIM MUTUAL INS CO 33758 I INSURED iNSURER B: BRANDON INC �wsur�Rc: INSURER D: 1319 ROUTE 28 INEURER E: SOUTH YARMOUTH MA 02664 ��r�p; COVERAGES CERTIFICATE NUMBER: 8812 REVISION NUMBER: T+IIS IS TQ EfRTIFY F+fAT TF1E PALJCIES E�F IPIS!lRANC,E�:JST€B B€LAW+IAVE B€€t+l IS�IdE��4sH�IIVSURED NAMED ABA��BR�M€-P�6X-PERlpp _-- INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER QOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICtES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, ' EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 POLICY EFF POLICY EXP ��7R TYPE OF INSURANCE � $� POLICY NUMBER MN D LIMITS COMAAERCIAL6ENERALLIABILITY EACHOCCURRENCE $ A T CLAIMS-MADE OCCUR PREMISES Ea occurrence S MED EXP(My me person) $ N!A PERSONAL&ADV INJURY $ GEN'L AGGREGATE L�MIT APPLIES PER: GENERAI AGGREGATE $ POLICY❑�E� �LOC PRODUCTS-COMP/OP AGG $ � OTHER: $ AUTOMOBILE WBII.ITY ��1 eMSINGLE LIMIT $ � ANY AUTO BODILY IhL1URY(P�person) $ . ALL ONMED SCHEDULED AUTOS AUTOS N�A BODILY INJURY(Per acddeM) f NON-OWNED PROPERTY OAMAGE � HIRED AUTOS AUTOS Per aceidmrt = $ UMBRELLA LIAB pCCUR EACH OCCURRENCE $ IXCESS IiAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ � WORKERS COMPENSATION X g q�'� ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOWPAR7NER/IXECUTIVE E.L.EACH ACCIDENT $ 'fOO,OOO A OFFICERIMEMBEREXCLUDED7 wA run uus AWC40070253722015A 02/03/2015 02l03/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE E 10�,� If yes.descrlbe under DESCRIPTION OP OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 _ _ _-- — - -ny,a - — —. __ _ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Addidonal Remarks SchedWe.mry be attached H more space la requtred� Workers'Compensation benefits will be paid to Massachusetts empioyses only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massadiusetts. This certficate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certiflcate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govllwd/workers-compensatioNinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOYE DESGRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATiON DATE THEREOF, NOTICE WILL BE DELIVER£D IN Yarmouth Heaith Dept. nccoRoaacEwrrHrHe�icvr�ovisior�s. '�; � 1146 Rt 28 AUTHORIZED REPRESENTATNE �wk t.Ls i South Yarmouth MA 02664 Daniel M.Cra n�ey,CPCU,Vice Presiderrt—Residual Market—WCRIBMA �1988-2014 ACORD CORPORATION. Ali rights reserved. ACORD 25(201M01) The ACORD name and logo are registered marks of ACORD