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� a � TOWN OF YARMOUTH BOARD OF HEALTH
� � APPLICATION FOR LICENSE/PERMIT 2 6 NOY �l � ZU15
`'°°' * Please com lete form and attach all necessa �� .��� r�ts ��b r 1 �
' Failure to do so will result in the retu��"yo .�ppli ati�n pfi� ' DEPT.
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ESTABLISHMENT NAME:��ea.,�o..� Z�`ED TAX ID:
LOCATION ADDRESS: �y E � Mo.'.r.�ec� w eS�t �Ia.rP..ov��,,M�A TEL.#: �08 - 1 �5 - b`i(o�
MAILINGADDRESS:�-:c��ns:c�a �c���. - Q'o 6nx \58o Spc�v�q�:e��,��n� o `-k55e 1
E-MAIL ADDRESS: �ni►��. os;��Cs s��e�wa.}� c o h-.
OWNER NAME: �g�ec�wcw� �--�-C __
CORPORATION NAME (IF APPLICABLE):
MANAGER'S NAME: �/1a�:c� ���ac�:o �- S�r� Mc,,rc�o,cr TEL.#: 5Q$-�T15�_.09l0�}
MAILINGADDRESS:1`4 E � M�:� S�-�c�� , Wts�- �4a� .�.o�s+-�., MA O2c�'l3 - 8to'T
P(�OL 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.
l. 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.
FO�D PROTECTIO�T MANAGERS - CERTIFICATIQNS: _ _ .
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. M ti.c i c)- �v r C�d. t� 2.
PERSON 1N CHARGE:
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
�. N���:�. Oo�a�;O 2. b��:� Q�.�q��h�
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 �Q��� �o�n o�c�: 0 2.
HEIMLICH CERTIFICATIONS: '
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich I
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#
___ __ . _---- ---- --f3�'��-�-��--SE£3�L3�--- --
- ---- _ - -—__ _ ,
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:
LICENSfi REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# �
<50 sq.ft. $50 >25,000 sq ft. $285 VENDING-FOOD $25 ;
Z<25,000 sq.ft. $I50 �3 =FROZEN DESSERT $40 ZTOBACCO $110 �J
NAME CHANGE: $15 AMOUNT DUE _ $ 26 a.00 '
*****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM*****
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ADMINISTRATION �
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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
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CERT. OF INSURANCE ATTACHED �
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED ✓
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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 OC�UPANCY: 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 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 forms can be i
obtained at the Health Department,or from the Town's website at www.yarmouth.ma.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 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 SITE PLAN.
DATE: � �v'l'� SIGNATURE:
PRINT NAME&TITLE:���o-\� `.... E�N.�•s�ta,n Tceas.���_ � �pze��a-y�'�"C"
Rev. 10/Ol/IS
� . � . �
� The Commonwealth ofMassachusetts
1
Department of Industrial Accidents
� Office of Investigations
; ` 1 Congress Street, Suite I00
_ Boston, NfA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legiblv
Business/Organization Name: ��ee�w�y �..L C d I 61 a S e e�wo. � Z-`�4o
Address:�� E . �c�:Y. ��ree�
City/State/Zip:`1n1es� `�a��o��-�.,N�A oze�c3 Phone#: 5a 8 -�� S - oq(Q �
Are you an employer?Check the appropriate boz: Business Type(required):
1.❑'� I am a employer with � employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ RestaurantlBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �, � Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• ❑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 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
� 4.❑ We are a non-profit organization,staffed by volunteers,
� with no employees. [No workers' comp. insurance req.] 12.0 Other �-�- �-
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
---- nraani�_atinn ShouldCheCkboX�1__ _------- . _ . --— - ---- ------- _
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name: p�e�S e S e e a����,. �� ,
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 number and ezpiration 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 well as civil penalties in the form of a STOP WORK ORDER and a fine '
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 certify,und r the pains and penalties of perjury that the information provided above is true and correct.
Si ature: - �
Date: /�
Phone#: `�3� ' $�3 - 7 382
Official use only. Do not write in this area,to be completed by city or town official �
City or Town: Permit/License# j
Issuing Authority(circle one): ;`'
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office !
6.Other (
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Contact Person• Phone#: �
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�wwwmass.gov/dia
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�'�'°'!�� CERTiF1CATE �F LIABILITY tNSURANCE 6,22;2`;5°""",
TH1S CERTIFICATE {S iSSU�Q AS A MATTER OF INFORMAFION QNLY AND CpNFERS NO FtIOHTS UPON TW£ CERTIFICATE HOIDER.THIS
' CE}2TIFICATE DpES NQT APFIRMATIYELY QR NEC+pTIVELY AMEND, EXTEMd OR ALTER THE COVERAGE AFFQRCIEO 8Y THE POLICIES
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BELAW. THi3 CERTIFICA7� OF IN5URANCE DOES NOT CpNSt1TUTE A GDN7RACT BETWEEN THE lSSUING tNSURER(3), AUTHORtZED
� REPRESSNTATIVE dit PRODUCER,AND THE CER7fFICATE HOLDER.
I NIAPORTANT: it the certifFcate holder is an ADDtTiONAL tNBURED,the poficy(ies]must kse endorsed. !f SUBRpGAT10N IS UYAIVED,subject ta
� the terms and conditions of the policy,certain potictes may require a�Bndarsement. A statement on thts certlficata doos not confer rights to tho
� certiflcate halder in lisu of such andorsement s. �
jPRODUCER NAME_--_.M�Ii$S�..LQY�..,_'-•--.-------_._...._._.__.___._.._ '
� Hylant Group-Cieveland PHONE �FAX�--�'� -�--�T'�
ns.���:z�s-4a.Z_1.Q�Q_.r.____.__._.____�_c+vc,►,012.16�4.4.2�4Il�---
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� Independence OH 44731 _^o--��-l-_-._.
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; SpEedway LLC IN9URERCS___.__.___......._____.__...._.______�_.—_�_....w._..�..._.._.__..�.._._.J_....._.__..�.---._.
i 500 5peedway Drive �MsuReao: � `
Enon,OH 4532� _._...___._._____..____-___.._._..___..___.......�..__........_._..�-•-.--+------------
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iNSURER F: .
1 CQVERAGES CERTtFICAtE NUMBER:37610060$ REVISION NUMBER:
THIS IS TO CERTIFY THA'f TNE POLtC1ES OF INSURAAICE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREQ N11ME0 AB1�VE F012 TNE POLICY P RIOD
INDICATE.O. NOTW{7HSTANpIMG ANY REQUIREMENT,TERM OR CONOITION OF ANY CONTf2ACT OR OTWER DOCUMENT WITH RESPECT Tp WHICH TNIS •
CEF�TIFICATE MAY Bf lSSUED OR MAY PER7AlN, THE INSUi2kNLH AFFOROE� BY 7HE PpIiCIES DESCRI8E4 N[REIN IS 5UBJECT 70 ALL FFiE TERMS,
EXCl.US10NS AND CONDITIONS OF SUCH POI.ICIE5.LIMITS SHOWN MAY HAVE BEfiN REDUGED filY PASD CtAIMS.
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i DEp �T R ENTtUN E � j S
q WORKERS COMPENSATION ' �MWC305127D0 �711l2015 7/712016 �X �S'fA7U- 4SH-
I � ANO EMPLOYERS'LIABILlTY Y!N f I r-�.�f3.L'L1BdL.S�--- -EB.�---_--'--._..._�._.._...__ �
ANY PRpV'+RtETOHiPAH7NERI�CECUTIYE I � I � �E_L_EACM ACCI1:tENT 55,000�000
IOFFICEWMEPh6EREXCWOf.p� � HtA; � i � --�----- i
I(Mandatary in NN) � � i � E.L O�5F.F+SE-EA EMPLpYE 55;000_000 __:__w �
�if Yea descnnbe un0er � �
!fiESCRIPTiGN OF OPERl,TtON5 to�ow S � � E.L.i]iSEnSE-POIiCY 1�M17 .S5 000,000
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DE5CRIPTION pF OPERATIONS I LOCATIONS 1 YEH�CLE5�Aftsch ACORD 101,Additionai RsmarKs Scpctluk.It mor4 spaCa Is requirea) �
CERTIFICATE NOLDER CAAICEL.LRTtON
SMOULD ANY OF THE ABOVB pESGRIBEO POL�IES BE CANCELLED 86FORE
THE EXPiRATION DAT'� THEREOF, NO71GE WtLL BE DELl1/ERED iN '
Evidence af Insurance-Speedway ACCORdANCE WITH THE pOIICY pROVI$IONS.
� ' ' ' AUTHORIZED REPRESENTATIVE � �
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m 1988-2010 ACqRD CqRPORATiON. Alt rights reServed. .
ACORD 25(2010105) The ACqRO nama and loga are registered marks of ACOR�